Safar Ali, a 25-year-old remand prisoner, died by hanging in his cell at Yatala Labour Prison on 10 April 2015. He had been remanded in custody following charges of attempted murder of his ex-partner. Initial assessments showed medium then low risk of self-harm; he was cleared from high-risk monitoring within weeks and placed in a working division in a single cell. On the day of death, he returned from court distressed after reading a newspaper article about his trial. He was found hanging from a bedsheet suspended from a cell shelf approximately two hours later. The coroner found the death could not have been predicted or prevented, as Mr Ali had shown no subsequent indication of self-harm risk despite underlying stress about his trial outcome. The coroner recommended continued vigilance for signs of distress when prisoners return from court and elimination of hanging points from all cells regardless of risk classification.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Contributing factors
acute distress related to ongoing trial
distress over newspaper article reporting trial evidence
concerns about conviction and further incarceration
availability of hanging point in cell
single cell accommodation
Coroner's recommendations
Correctional Officers should be vigilant for any signs of distress when prisoners return from any escort, including video conference in court, police escorts, medical appointments, compassionate leave, court or parole board proceedings, and transfers from other locations. Any concerns must be verbally notified to the Responsible Officer and a Notice of Concern completed as soon as reasonably possible.
Hanging points should be eliminated from all cells regardless of the type of accommodation within the prison system and regardless of the risk assessment pertaining to a particular prisoner, especially those that provide single occupancy.
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