Coroner's Finding: VARCOE Alexander Wayne Keith
Deceased
Alexander Wayne Keith Varcoe
Demographics
24y, male
Date of death
2000-12-17
Finding date
2003-03-20
Cause of death
hanging
AI-generated summary
Alexander Varcoe, a 24-year-old Aboriginal man, died by hanging in Yatala Labour Prison while on remand awaiting trial for serious charges. He had a complex history including prior self-harm in 1995-96, alleged prison rape, substance abuse, and a troubled childhood, but appeared mentally stable in December 2000. Critical systemic failures included: failure to properly interpret a suicide risk screening form identifying him as at-risk upon admission; inadequate investigation procedures that failed to determine time of death; extensive unaddressed hanging points in cell design; and incomplete follow-up on alleged previous sexual assault within the prison. While clinicians had inadequate information due to non-reporting of the alleged rape, the coroner found no overt suicide risk indicators in the weeks preceding his death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- failure to act on suicide risk screening form results at admission
- inadequate follow-up on history of self-harm and prior psychiatric assessment
- unreported prior sexual assault within prison
- inadequate cell design with multiple hanging points
- unresolved family separation issues and contact difficulties
- lack of immediate cellmate after cellmate transferred to infirmary
- inadequate investigation procedures that failed to determine time of death
Coroner's recommendations
- The Department of Correctional Services review the Prison Stress Screening form in light of the issues discussed in this inquest, including clarification of when physical inspection for scars is required
- The design of cells in E division at Yatala Labour Prison, and all older cells in the South Australian prison system, should be subject to comprehensive review along the lines of the Victorian Building Design Review Project to reduce hanging points
- The Commissioner of Police reinforce with investigating officers and supervisors the need to comply with the protocol for investigation of deaths in custody, particularly in relation to determining the time of death, including ensuring pathologists are called to death scenes or alternative arrangements made
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