Coroner's Finding: KEANE Shaun Martin
Deceased
Shaun Martin Keane
Demographics
31y, male
Date of death
2012-07-15
Finding date
2017-11-17
Cause of death
carbon monoxide toxicity
AI-generated summary
Shaun Martin Keane, aged 31, died by carbon monoxide toxicity while on home detention bail following arrest for assault. He had a documented history of suicidal ideation, including a previous gassing attempt in 2010, and had experienced significant trauma including alleged sexual assault in prison. While on home detention, he received mental health support from a GP, psychologist, and social worker, all of whom assessed him as not currently suicidal. However, the bail assessment report failed to document his suicide risk history despite this information being available in custodial records. Critical clinical lessons include ensuring mental health risk factors are explicitly documented in bail/risk assessments, maintaining heightened vigilance when patients report trauma or assault, and recognizing that multiple negative life events (imprisonment, denied access to children, sexual assault concerns) can precipitate acute suicide risk despite recent reassurances.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- documented history of suicidal ideation and previous suicide attempt by gassing
- trauma from alleged sexual assault in prison
- depression and anxiety
- amphetamine and benzodiazepine use
- recent loss of contact with children
- fear of returning to prison
- bail assessment report failed to document suicide risk despite custodial risk information being available
- loss of employment while on home detention
Coroner's recommendations
- DCS staff members responsible for compiling Bail Inquiry (Home Detention) Reports be instructed to make specific reference to any information relevant to the applicant's risk of self-harm or suicide
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