Coroner's Finding: DEWSON Brian Keith
Deceased
Brian Keith Dewson
Demographics
33y, male
Date of death
2000-11-05
Finding date
2004-02-13
Cause of death
hanging
AI-generated summary
Brian Dewson, a 33-year-old man with a 12-year history of drug and alcohol abuse, multiple psychiatric assessments (antisocial personality disorder, depression), and prior suicide risk designations died by hanging in Port Augusta Prison in November 2000. Despite two previous suicide risk assessment care plans within 12 months, there were no clear indications in the week preceding death suggesting imminent suicide. Staff responded appropriately with immediate Code Black, cell access within 2 minutes, and immediate CPR. However, cell design and master key placement created avoidable delays. The coroner noted that deaths might be prevented through electronic cell opening systems and implementation of 'safe cell' design principles that were not yet implemented at the prison.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- Cell design with multiple hanging points (shelf-to-wall gap of >1cm and shelf-to-bracket gap of 1mm)
- Master key location remote from housing unit causing 2-minute delay to cell access
- History of antisocial personality disorder, polysubstance abuse, and depression
- Relationship breakdown and marital conflict (pending divorce)
- Separation from children and family distress
- Impulsive and erratic behavioural patterns
Coroner's recommendations
- The Chief Executive Officer, Department for Correctional Services, should reconsider the system whereby access to a prisoner's cell may only be gained with a master key kept in the Main Control Room. In particular, the feasibility of a system whereby the cell could be opened electronically from the Main Control Room should be investigated.
- The 'safe-cell' principles should be adopted and implemented in prisons throughout South Australia as a matter of urgency.
Full text
Related cases
Source and disclaimer
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. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. 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 —