Deceased
BCA
Demographics
26y, male
Date of death
2018-02-09
Finding date
2021-10-21
Cause of death
neck compression in the circumstances of hanging
AI-generated summary
A 26-year-old prisoner with a history of depression died by hanging in custody at Langi Kal Kal Prison. He had been prescribed desvenlafaxine for depression and was assessed regularly by medical staff throughout his incarceration, consistently denying suicidal ideation. Four days before his death, he stopped taking his antidepressant medication for one to two days (initially forgetting to collect it, then reporting ongoing non-compliance). Prison staff noted mood changes and anxiety but did not identify suicide risk. The coroner found the clinical management was appropriate by current standards, with regular mental health reviews and proper medication administration. No clinical error or failure in care was identified. The death was investigated thoroughly following anonymous allegations of foul play, which were excluded by forensic evidence and police investigation.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Drugs involved
Clinical conditions
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PE, aged 53, died by hanging in Parklea Correctional Centre on 3 February 2024, four days after entering custody for the first time on remand. The coroner found PE's death was self-inflicted at a time of emotional turmoi…
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Corey Desmond Devree, aged 41, died by suicide in Bunbury Regional Prison on 14 October 2024 through ligature compression of the neck and a self-inflicted stab wound to the chest. Key clinical and systemic lessons includ…
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