Coroner's Finding: FREDERICKS Jeffrey Ronald
Deceased
Jeffrey Ronald Fredericks
Demographics
41y, male
Date of death
2001-05-04
Finding date
2004-08-06
Cause of death
haemorrhage due to incised wounds to left and right cubital fossae
AI-generated summary
Jeffrey Ronald Fredericks, aged 41, died in Adelaide Remand Centre custody from haemorrhage due to self-inflicted incised wounds to both cubital fossae. Critical clinical lessons: screening tools identified significant suicide risk (Prison Stress Screening Form score 11 with positive responses to suicidal ideation questions), but subsequent medical assessment by Dr K. was inadequate. The assessment lasted only 7-10 minutes for both physical and mental health evaluation, without documentation of depressive symptoms, assessment of stressors, or follow-up planning. Despite being flagged as at-risk, Fredericks was transferred from observation to general population based on his denial of suicidal thoughts and statement he was 'feeling much better'. A more thorough mental state assessment, with adequate time and documentation, before transition from observation may have enabled more rigorous ongoing monitoring. Emergency response and resuscitation efforts were exemplary. The clinical failure was at the assessment and risk stratification stage.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- inadequate mental state assessment despite positive suicide risk screening
- insufficient time allocated to medical evaluation in custody setting
- lack of documentation of depressive symptoms and stressors
- transfer from observation unit to general population based on incomplete assessment
- no follow-up arrangement for antidepressant monitoring
- prisoner denial of suicidal thoughts not adequately explored or verified
Coroner's recommendations
- Examine the time available to clinicians within correctional facilities to ensure sufficient time for appropriate mental state examination before a prisoner assessed as not being at risk of self-harm is transferred from observation areas
- Consider special arrangements for assessment of prisoners being considered for transfer from areas designated for surveillance of 'at risk' prisoners to ensure adequate mental health assessment occurs before such transfer decisions are made
Full text
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. 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.