Coronial
TASprison

Coroner's Finding: Gerard, Robert Harold

Deceased

Robert Harold Gerard

Demographics

48y, male

Date of death

2022-05-23

Finding date

2024-04-18

Cause of death

Hanging (partially suspended hanging using shoelaces as ligature)

AI-generated summary

Robert Harold Gerard, aged 48, died by hanging in Risdon Prison in May 2022 while on remand for serious charges. He had paranoid schizophrenia, a long history of substance abuse, and was experiencing depression and suicidal ideation. The coroner found his mental health care was reasonable but limited by grossly inadequate psychiatric staffing (described as the lowest in any developed country). Key clinical lessons include: individual suicide risk assessments have significant limitations and cannot predict suicide reliably; the mention of shoelaces during a RIT review with concurrent suicidal ideation and weight loss warranted greater clinical significance; psychiatric review gaps occurred due to resource constraints; and environmental hazards (obvious hanging points in shower areas) persist despite prior recommendations. The coroner recommended urgent review and expansion of mental health services in prisons, elimination of obvious ligature points, and replacement of laced footwear with slip-on shoes to prevent future deaths.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

psychiatrycorrectional health

Error types

systemdelaycommunication

Drugs involved

zuclopenthixol decanoatemirtazapinesodium valproateolanzapine

Clinical conditions

paranoid schizophreniamajor depressive episode / schizoaffective disorder depressive typesubstance use disorder (alcohol, cannabis, methamphetamine)post-traumatic stress disorder (historical)suicidal ideationCOVID-19 infection

Contributing factors

  • Inadequate psychiatric staffing and resources in prison mental health services
  • Depression and suicidal ideation in context of psychotic illness
  • Weight loss, anhedonia, and hopelessness
  • Stress from serious criminal charges and remand
  • COVID-19 infection and unit quarantine
  • Frequent prison lockdowns (79 lockdowns in 22 days prior to death)
  • Availability of shoelaces despite previous coronial recommendation to ban them
  • Obvious and unmodified ligature points in shower area
  • Gaps in psychiatric review due to leave and staffing constraints
  • Negative symptoms of schizophrenia (flatness, withdrawal, anhedonia)

Coroner's recommendations

  1. Conduct urgent review of mental health care services in the Tasmanian Prison Service to ensure compliance with international (Mandela Rules) and national (Guiding Principles for Corrections) healthcare standards, with adequate resourcing and staffing
  2. Develop and implement plans to remove all, or as many as are reasonably possible, hanging points in accommodation and communal living areas of the medium security precinct of RPC, including removal of the hanging point used by Mr Gerard and any similar hanging points
  3. Undertake risk assessment of particular hanging points whenever a death or attempted suicide by hanging occurs, with view to eliminating that point and any identical points within the prison system
  4. Give greater consideration to identifying potential hanging points when reviewing draft architectural plans for new building works and all modifications
  5. Implement a blanket policy requiring slip-on footwear to replace all footwear with laces for all prisoners and detainees in the Tasmanian Prison Service, consistent with Coroner Cooper's 2017 recommendation
  6. Ensure all first responder staff carry cut-down knives (fish knife design) to enable rapid cutting down of inmates without delay
  7. Issue unit keys to medium security communications officer or medium security correctional supervisor positions to reduce delays in emergency access to units
Full text
Official source Archived copy

Related cases from TAS

TAScommunity2026-02-23

Coroner's Finding: de-identified VY

33y · Female·hanging

A 33-year-old woman with significant history of mental health issues, depression, anxiety, suicidal ideation and prior suicide attempts died by hanging while highly intoxicated (BAC 0.183g/100mL). She used a length of te…

psychiatryemergency medicinesystemalcohol
TAScommunity2026-01-13

Coroner's Finding: Joshua James Tyrrell

28y · Male·Multiple head, facial and spinal injuries sustained in a single vehicle motorbik…

Joshua Tyrrell, 28, died from multiple head, facial and spinal injuries sustained in a motorbike crash on the Brooker Highway. He was riding at excessive speed and failed to maintain steering control through a bend. Toxi…

general practiceemergency medicinemedicationcommunicationdiazepam
TAScommunity2025-12-03

Coroner's Finding: de-identified JI

54y · Male·Global hypoxic brain injury, cardiac arrest and blunt trauma to cervical spine

JI, a 54-year-old man with chronic schizophrenia, died from global hypoxic brain injury, cardiac arrest and cervical spine trauma following a fall onto a metal grate during an altercation with another resident at support…

psychiatrygeneral practicesystemdiazepam

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. Some material may have been redacted or restricted by court order or privacy requirements. 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 — report an inaccuracy here.