Inquest into the death of Garry Reginald Dubois
Deceased
Garry Reginald Dubois
Demographics
74y, male
Date of death
2021-06-07
Finding date
2026-01-30
Cause of death
Incised wounds to limbs; other significant conditions being ischaemic heart disease and antiplatelet therapy
AI-generated summary
Garry Reginald Dubois, a 74-year-old serving a life sentence for serious offences, died in custody from self-inflicted incised wounds to his limbs. He was on dual antiplatelet therapy for ischaemic heart disease, which contributed to fatal haemorrhage. The coroner found his medical care, mental health care, and supervision were adequate and appropriate. No mental health risk was identified despite his serious crimes and extended sentence. A prisoner who knew him reported Dubois had expressed suicidal intent months prior without disclosure to staff. His family made multiple emotional goodbye calls the day before his death. The coroner found the provision of razor blades was appropriate as he was not assessed as at-risk. The inquest identified minor resuscitation delays but concluded these were not outcome-changing. No systemic failures or preventability findings were made.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Contributing factors
- Dual antiplatelet therapy increasing bleeding risk
- Underlying ischaemic heart disease limiting cardiac reserve
- Access to razor blade
- Isolated cell placement limiting observation
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