A 58-year-old man remanded in custody awaiting trial died by hanging in prison. He had a history of depression treated with fluoxetine and was assessed by a forensic psychiatrist who found no evidence of depression or suicidal ideation. Prison staff and family observed mood fluctuations but no overt suicide intent, except to his partner who described frequent suicidal statements but did not report these to authorities. He wrote letters in contemplation of death in November 1997. Correctional officers conducted two-hourly cell checks but did not observe his death; he constructed a convincing mannequin to conceal his absence. Clinical lessons include: ensuring comprehensive suicide risk assessment in custodial settings captures information from all contacts; improving communication between informal sources and authorities; and mandating direct observation of prisoner wellbeing during checks rather than observation of body shape alone.
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Specialties
psychiatrygeneral medicine
Error types
communicationsystem
Drugs involved
fluoxetine
Clinical conditions
depressionsuicidal ideation
Contributing factors
history of depression not fully communicated to prison authorities
suicide risk information held by partner not reported to prison
inadequate prisoner welfare checks during counts
checks limited to observation of body shape rather than direct observation of breathing or vital signs
cumulative stress from legal proceedings, confinement, and personal circumstances
Coroner's recommendations
Amend Duty Statements for 1st and 2nd Watch Officers conducting prisoner counts to require staff to take reasonable steps to ensure wellbeing of all prisoners during two-hourly counts by direct observation of prisoner's breathing or skin, rather than observation of body shape alone
Law Society of South Australia and Department for Correctional Services should engage in dialogue to address prisoner concerns regarding access to legal representation and preparation time for defence
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