Cartledge, Adam
Deceased
Adam Cartledge
Demographics
38y, male
Date of death
2010-10-05
Finding date
2012-08-29
Cause of death
Hanging
AI-generated summary
Adam Cartledge, 38, died by hanging in his cell at Arthur Gorrie Correctional Centre while on remand. He had a long history of psychiatric illness, including depression, paranoid schizophrenia, previous suicide attempts, and chronic back pain. He was appropriately identified as elevated baseline risk (EBR) at induction and received psychiatric and psychological services. However, he was housed in an old-style, non-suicide-resistant cell with easily accessible hanging points despite his risk status. The Coroner found medical care was adequate and there was no obvious deterioration in mental state in the weeks prior to death that should have alerted staff. The emergency response was appropriate given initial uncertainty about whether a genuine emergency existed. The key clinical lesson is that prison health services must work with custodial staff to ensure EBR prisoners are housed in suicide-resistant cells, and that infrastructure improvements to eliminate accessible hanging points are essential for suicide prevention.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- housing in non-suicide-resistant cell despite elevated baseline risk status
- easily accessible hanging points in older style cells
- chronic depression and history of multiple suicide attempts
- chronic back pain
- dissatisfaction with psychiatric and analgesic medication
- initial skepticism by staff regarding emergency call
- removal from elevated baseline risk review process prior to death
Coroner's recommendations
- When allocating prisoners to secure accommodation at AGCC, prisoners who have a self harm flag should be placed in modern suicide resistant cells unless other reasonable factors warrant against it
- Where flagged prisoners are not allocated to modern cells, the reasons for the individual decision should be recorded
- Representatives from QCS and GEO Australia Pty Ltd should meet to examine and progress necessary changes at AGCC with a view to increasing the number of prisoners with self harm flags accommodated in suicide resistant cells
- All cells at AGCC with exposed hanging points should be progressively replaced with suicide-resistant cells to align with recommendations from the Royal Commission into Aboriginal Deaths in Custody
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