Coronial
SAother

Coroner's Finding: STURT Royston Henry

Deceased

Royston Henry Sturt

Demographics

58y, male

Date of death

1998-01-14

Finding date

2000-11-28

Cause of death

hanging

AI-generated summary

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.

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

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

  1. 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
  2. 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
Full text

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