Deceased
Colin David Johnson
Demographics
53y, male
Date of death
2011-05-06
Finding date
2015-03-27
Cause of death
Complications arising from blunt force trauma to the head
AI-generated summary
Colin David Johnson, aged 53, died from complications of severe blunt force head trauma sustained during an assault in a prison day room on 23 April 2011. The attack occurred in full view of a prison office with a clear window, yet was not observed by correctional officers. Six hours passed before injuries were detected. The coroner found the death preventable: earlier observation would have enabled prompt hospital transfer and medical intervention, which may have changed the outcome. Key failures included inadequate lockdown procedures that did not require face-to-face verification of prisoner welfare, absence of CCTV cameras in the day room despite being the primary assault location, and apparent inattentiveness of correctional officers. The coroner recommended installation of CCTV cameras in prison day rooms.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Procedures
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