Coronial
QLDother

Hurst, Charles Kingston

Deceased

Charles Kingston Hurst

Demographics

38y, male

Date of death

2012-11-07

Finding date

2014-09-16

Cause of death

Hanging

AI-generated summary

Charles Hurst, a 38-year-old man with schizophrenia, depression and anxiety, died by hanging in his prison cell while in custody at Maryborough Correctional Centre in November 2012. He had been assessed using the Queensland Corrective Services At-Risk Management procedure and was classified as low risk on 5 November 2012, two days before his death. While the psychiatric care and risk assessment procedures were generally appropriate, a critical failure in prison equipment standards enabled the suicide: laundry bag drawstrings were thinner than approved design specifications, allowing Hurst to access the air vent as an attachment point for a ligature. The coroner found the At-Risk procedure was properly applied and noted that family concerns raised shortly before death did not specifically mention suicidal ideation. Key lessons include maintaining equipment safety standards, not undervaluing current symptoms based on past behaviour, and ensuring consistency in security protocols across all facilities.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

psychiatrycorrectional health

Error types

system

Drugs involved

mirtazapinechlorpromazine

Clinical conditions

schizophreniadepressionanxietysuicidal ideationalcohol and drug withdrawal

Contributing factors

  • laundry bag drawstring thinner than approved design specifications
  • accessibility of air vent as attachment point
  • underlying schizophrenia with delusional ideation
  • transient suicidal ideation not consistently expressed
  • potential undervaluation of current symptomology based on past behaviour

Coroner's recommendations

  1. QCS reiterate support for the 2013 Health Prison Inspection recommendation that staff should not undervalue current symptomology on the basis of past experience of the prisoner by re-communicating this information statewide to all centre management and psychological services staff
  2. QCS implement a resilience training or education program for a specified cohort of prisoners who are identified as a high elevated risk of suicide on a statewide basis
  3. Centres be required to obtain the approval of the Safety and Security Committee in respect of proposed non-urgent changes to practice that are inconsistent with safety or security related directions issued by the Statewide Operations directorate, such as changes to designated adjustment mechanisms for laundry bags. In addition, urgent changes that are approved by statewide operations outside the Safety and Security Committee process should be submitted in the next committee meeting for endorsement
Full text
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Source and disclaimer

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