Coroner's Finding: SANSBURY Colin Craig
Deceased
Colin Craig Sansbury
Demographics
24y, male
Date of death
2004-11-17
Finding date
2007-07-12
Cause of death
diffuse hypoxic ischaemic encephalopathy due to hanging
AI-generated summary
Colin Craig Sansbury, 24-year-old Aboriginal man, died by hanging while in police custody at Elizabeth Police Station. Critical failures in care included: (1) Inadequate psychiatric assessment at Lyell McEwin Hospital—he was drowsy and unable to provide history, yet discharged without psychiatric evaluation despite police specifically requesting this; the examining registrar signed off without reading the referral form indicating self-harm concerns; (2) Failure to supervise a prisoner known to be at-risk—he was left alone for 40 minutes without checks, despite being flagged as requiring close observation after expressing suicidal ideation; (3) Inappropriate deployment of an Aboriginal Community Constable who, exploiting cultural trust, offered hope of bail in exchange for information, then failed to deliver, increasing despair; (4) The disposable jumpsuit used for the ligature should have been removed. The coroner found the death was preventable with appropriate psychiatric assessment and consistent prisoner checks.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- inadequate psychiatric assessment at emergency department despite police referral requesting psychiatric evaluation
- examining doctor failed to read referral form indicating self-harm concerns before discharge
- insufficient time spent on assessment; patient drowsy and unable to provide coherent history
- lack of communication between junior doctor and senior registrar regarding clinical concerns
- premature discharge from hospital without psychiatric assessment or overnight observation
- prisoner categorized as 'at-risk' but not properly supervised on morning of death
- failure to conduct regular checks on at-risk prisoner; 40-minute gap without observation
- CCTV monitoring inadequate due to cell lights being off, reducing visibility
- inconsistent understanding among officers regarding frequency and nature of prisoner checks
- access to disposable jumpsuit which was fashioned into ligature
- use of Aboriginal Community Constable for intelligence-gathering created false hope regarding bail, increasing distress
- delay in charging process due to inappropriate 'debriefing' activities
- lack of clear communication to day-shift officers regarding at-risk status of prisoner
Coroner's recommendations
- Discontinue deployment of Aboriginal Community Constables for 'debriefing' purposes
- Attorney General should negotiate with State and Commonwealth counterparts to establish arrangements for deaths in police custody in one jurisdiction to be investigated by police from another jurisdiction or Federal Police, to avoid perception of defensive investigation
Full text
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