Deceased
Robert Allen Johnson
Demographics
37y, male
Date of death
2005-09-21
Finding date
2007-09-26
Cause of death
Hanging
AI-generated summary
Robert Allen Johnson, aged 37, died by hanging in his prison cell at Yatala Labour Prison on 21 September 2005. He had been remanded in custody the previous day on serious charges. Upon admission, he was initially assessed as potentially suicidal but was re-assessed 90 minutes later and deemed not to be at suicide risk. Staff noted he was calm, polite, and had good family support. He was placed alone in a cell with a double bunk bed. He was discovered suspended from the upper bunk in the early hours of the morning. The coroner found staff appropriately assessed him but identified a systemic failure: the prison's double bunk beds were inherently unsafe, providing obvious ligature points. The coroner noted this same issue had been identified in previous inquests and that safe prototype beds existed but had not been implemented.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
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