Coronial
VIChome

Finding into death of Tre Leigh Lawson

Deceased

Tre Leigh Lawson

Demographics

21y, male

Date of death

2017-11-15

Finding date

2019-10-07

Cause of death

Hanging

AI-generated summary

A 21-year-old Aboriginal man died by hanging following a tumultuous relationship involving family violence, substance abuse, and unmanaged mental health issues. He had attempted self-harm in May 2017 and was assessed as low imminent risk but never engaged with recommended mental health services. A critical missed opportunity occurred when the court assessor conducting his pre-sentence assessment for a Community Corrections Order in October 2017 failed to recommend mental health treatment conditions, despite evidence of prior required attendance at mental health services and documented self-harm attempts. Better integration of mental health assessment in regional courts, earlier intervention, and ensuring compliance with mental health referrals could have provided opportunities for prevention.

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

Contributing factors

  • Unmanaged mental health issues despite prior assessment and court-ordered requirement to attend treatment
  • Substance abuse (methylamphetamine, amphetamine, cannabis)
  • Family violence and relationship conflict with intimate partner
  • Failure to implement mental health treatment conditions in Community Corrections Order
  • Lack of mental health advice service at regional court
  • Non-compliance with court-ordered mental health treatment referral

Coroner's recommendations

  1. Expand the Forensic Mental Health Implementation Plan and Mental Health Advice and Response Service to operate in regional areas with identified high rates of indigenous suicide, particularly at the Mildura Magistrates Court
  2. Establish clinical mental health advice services within regional courts to improve mental health interventions and referrals for individuals appearing before the court
  3. Ensure early intervention and linkage with treatment providers through expanded mental health advice services in regional Victorian areas
Full text

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