Deceased
Barry Michael Turner and Troy Michael Glennie
Date of death
2004-02-09
Finding date
2006-10-18
Cause of death
Neck compression due to hanging (self-inflicted)
AI-generated summary
Two men, Barry Michael Turner (35) and Troy Michael Glennie (28), died by hanging in Adelaide Remand Centre while on remand. Both had expressed suicidal ideation and were being monitored via 'yellow sheet' daily nursing assessments. Turner's assessment was omitted from the monitoring list thirteen days before his death due to a system failure where his yellow sheet remained in his file rather than being returned to the clipboard used by nurses. Glennie was removed from daily assessment by a psychiatrist who determined he was improved, despite warning signs. Key clinical failures included: inadequate communication between psychiatry and corrections staff; fragmented information systems preventing access to psychology/social work notes; removal of cellmates leaving vulnerable prisoners alone; and lack of safe cell design. System changes post-death included improved yellow sheet tracking, mandatory doubling-up when cellmates are removed, and multi-disciplinary high-risk assessment teams. The coroner emphasised that better documentation, clearer continuation of monitoring protocols, safer cell design with no hanging points, and accessible unified record systems could prevent recurrences.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
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