Sloan, Dane Benjamin
Deceased
Dane Benjamin Sloan
Demographics
24y, male
Date of death
2013-10-06
Finding date
2017-02-10
Cause of death
Hypoxic ischaemic encephalopathy due to or as a consequence of being hanged
AI-generated summary
Dane Benjamin Sloan, a 24-year-old remand prisoner with mental health history including suicidal ideation, hanged himself in the Maximum Security Unit exercise yard at Brisbane Correctional Centre. Although CCTV monitored the exercise yard, the control room operator could not observe Sloan's actions due to limited camera angle and image quality. He remained unobserved for approximately 16 minutes while hanging. Sloan had been removed from formal observations five days prior based on risk assessment. Resuscitation attempts were appropriate but unsuccessful; he died from hypoxic ischaemic encephalopathy. Key lessons include: improved CCTV systems with multiple angle visibility are essential; staff fatigue monitoring is critical; control room operators require adequate support; and despite proper risk assessment processes, infrastructure limitations may compromise safety even when psychological assessment indicates reduced risk.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Drugs involved
Contributing factors
- Limited CCTV camera angle available to control room operator
- Poor image quality and distortion from protective camera covering
- Single operator monitoring large number of camera feeds simultaneously
- Operator fatigue due to extended screen monitoring
- Removal from formal observations regime despite mental health history
- Inadequate personal search before exercise yard access
- Insufficient lighting and clarity of monitoring displays
- Staff complacency identified in root cause analysis
- Unavailability of front-on camera angle to control room monitors
Coroner's recommendations
- QCS should ensure replacement CCTV monitoring systems clearly display all relevant camera angles, with particular consideration to potential hanging points within cells and exercise yards in the MSU
- Ensure the best available camera angle with reference to potential hanging points can be displayed clearly to main control room monitors
- Explore the merits of a policy of more frequent rotations of officers through the control room to minimise fatigue and loss of focus during extended screen monitoring
- Implement training to address staff complacency in the MSU, with reference to Mr Sloan's death as an illustrative case
- Ensure all MSU officers receive proper training in personal search procedures as defined in the Custodial Operations Standard Operating Procedure
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