Deceased
Robert Gary Mitchell
Demographics
34y, male
Date of death
2008-07-09
Finding date
2012-01-20
Cause of death
self-inflicted hanging
AI-generated summary
Robert Gary Mitchell, age 34, died by self-inflicted hanging in cell 13 of Arthur Gorrie Correctional Centre on 9 July 2008. He was on remand without prior documented suicidal ideation or psychiatric history. Initial risk screening on reception was negative (with a later noted administrative form error). He expressed anxiety about court proceedings the day before death. A welfare check at 7:57pm found no concern. The subsequent head count at 11:54pm (4 hours later) discovered him hanging. While initial policy-driven delays in cell access occurred, post-mortem revealed recent self-harm marks on his wrist. Clinical lessons: this was an unidentifiable suicide risk; the primary preventable factor was the exposed hanging point in the cell rather than clinical assessment failure. The coroner emphasised that without ability to identify at-risk individuals, all cells must eliminate hanging points.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
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