A 29-year-old man remanded in custody at Adelaide Remand Centre died by hanging on 15 January 2000. At admission, he denied self-harm risk and psychiatric history; no warning signs were identified. He was found hanging from a bed sheet tied to a bunk rail during morning head count. Resuscitation was promptly initiated and performed competently but was unsuccessful. Clinical lessons include: (1) the importance of thorough risk assessment at custody admission, particularly for those charged with serious offences; (2) the need for accurate cell checks and honest logging of observations (a supervisor falsely documented a 2am check); (3) procedural improvements in death-in-custody investigations, including early pathologist attendance to determine time of death; and (4) environmental design considerations to eliminate hanging points in custodial settings. The resuscitation response was appropriate and commendable.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
forensic medicineemergency medicineparamedicinecorrectional health
Error types
communicationsystemdelay
Procedures
cardiopulmonary resuscitationdefibrillation
Contributing factors
inadequate risk assessment at admission
false entry in cell check log
delay in pathologist attendance to determine time of death
cell design allowing hanging point from bunk bed rail
Coroner's recommendations
The Department for Correctional Services reinforce with custodial staff that the making of false entries in logs is an extremely serious matter which should not be tolerated by other staff
The protocol between the Commissioner of Police and the Coroner should be amended to ensure that a pathologist is called to the scene of a death in custody wherever possible, and where that is not possible, gives directions as to the alternative arrangements that can be made to determine the time of death
The Department for Correctional Services review all bunk beds with a view to minimising obvious hanging points, or if this is not possible, bunk beds in all cells should be removed
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.