Coronial
QLDother

SVE

Deceased

SVE

Demographics

43y, male

Coroner

Ryan

Date of death

2019-03-16

Finding date

2021-05-24

Cause of death

Hanging

AI-generated summary

A 43-year-old man remanded in custody for serious sexual offences against children died by hanging in an older prison cell. While he expressed fears about safety and had passive suicidal ideation months before his death, there was no clear evidence of intent to self-harm in the days preceding his death. A psychologist referral form completed three weeks before death was not properly processed, and a complaint letter about safety concerns was not actioned. The coroner found that improved mental health referral processes and safer cell design (to eliminate hanging points) may reduce future deaths, though current risk management procedures were considered appropriate. The coroner recommended annual updates on safer cell implementation progress.

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

Specialties

psychiatrypsychologycorrectional healthgeneral medicine

Error types

systemdelaycommunication

Clinical conditions

anxiety disorderpassive suicidal ideationdepressionshame and remorse related to criminal charges

Contributing factors

  • Anxiety about being identified in prison as a child sexual offender
  • Fear of harm from other prisoners
  • Remorse about offences and self-perception as 'bad person'
  • Separation from family, particularly teenage sons
  • Awareness of lengthy prison sentence facing
  • Lack of timely response to psychologist referral request
  • Delayed processing of safety complaint letter
  • Encounter with prisoner AL whom he feared
  • Availability of hanging points in old stock cells
  • Mental health referral process delays (2-4 week wait to see psychologist with 100+ prisoners on waiting list)

Coroner's recommendations

  1. The Chief Superintendent, AGCC, ensure that prisoner request systems are reviewed to ensure that request forms completed by prisoners are collected daily, are appropriately prioritised and escalated, and that adequate resources are available to respond to prisoners' requests
  2. The Chief Superintendent, AGCC, implement an oversight and assurance process to ensure that prisoners receive an adequate induction when they first arrive at AGCC
  3. The Queensland government publish annual updates detailing its strategy for the implementation of safer cells and progress against that strategy
Full text
Official source Archived copy

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Source and disclaimer

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