Coroner's Finding: HARRIS Philip Michael
Deceased
Philip Michael Harris
Demographics
30y, male
Date of death
2015-09-17
Finding date
2019-05-23
Cause of death
exsanguination due to division of left brachial artery
AI-generated summary
Philip Michael Harris, aged 30, died in Yatala Labour Prison from exsanguination following self-inflicted lacerations to his left forearm that severed the brachial artery. He had a longstanding history of self-harm behaviour, borderline antisocial personality disorder, and mental health presentations. Despite being identified as high-risk on admission and placed under intensive observation, he spontaneously became agitated and cut himself without warning. Prison officers responded appropriately, but the injury was catastrophic. The coroner found no clinical issue with his carbamazepine dosing for epilepsy, which was within therapeutic range and showed no toxicity signs. Key lessons include the difficulty of preventing self-harm in custody despite appropriate risk identification, the unpredictability of acute self-harming behaviour, and the need to balance prisoner safety with practical prison operations regarding razor access.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Drugs involved
Contributing factors
- self-inflicted lacerations to left forearm using razor blade
- chronic history of self-harm behaviour
- borderline antisocial personality disorder
- recent loss of mother and emotional distress
- access to razor within prison
- unpredictable acute agitation without preceding warning signs
Coroner's recommendations
- Department for Correctional Services to review and update standard operating procedures regarding access to razors by prisoners, particularly those at high risk of self-harm, to achieve a balance between prisoner care needs and safety risks
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