Coroner's Finding: GIBSON Justin Lee
Deceased
Justin Lee Gibson
Demographics
30y, male
Date of death
2011-10-05
Finding date
2015-01-30
Cause of death
mixed butane, isobutane and propane toxicity
AI-generated summary
Justin Lee Gibson, a 30-year-old Indigenous man on home detention bail, died from inhalation of butane/propane causing fatal cardiac arrhythmia. He had a documented history of substance abuse (alcohol, cannabis, and butane) recorded by Prison Health Services during his August 2011 custody, but this information was not accessible to Department for Correctional Services staff responsible for bail supervision. Despite bail conditions prohibiting drug/alcohol consumption and recommendations for psychiatric assessment before release, no pre-release psychiatric evaluation occurred. Gibson consumed butane regularly during home detention without detection or specific testing. Clinical lessons: improved information sharing between custodial health services and correctional supervision staff; specific substance screening protocols aligned with documented abuse histories; and consideration of pre-release psychiatric assessment when mental health concerns identified.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- inhalation of butane from aerosol canisters
- cardiac arrhythmia (ventricular fibrillation and ventricular tachycardia)
- failure to communicate solvent abuse history from Prison Health Service to Department for Correctional Services
- inadequate substance testing during home detention supervision
- lack of psychiatric assessment prior to bail release despite recommendation
- untreated or inadequately managed psychotic symptoms and auditory hallucinations
- substitution of butane for prohibited alcohol and cannabis due to bail conditions
Coroner's recommendations
- When compiling Bail Enquiry Reports, Department for Correctional Services should seek out and have regard to relevant information contained within the bail applicant's most recent Prison Health Service records compiled whilst the applicant has been in custody. If consent is required and withheld, this should be a matter the Court may take into account when assessing the prisoner's candidacy for bail.
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 —