Finding into death of Joanne Finch
Deceased
Joanne Finch
Demographics
42y, female
Date of death
2018-07-24
Finding date
2021-05-07
Cause of death
Neck compression due to self-suspension
AI-generated summary
Joanne Finch, a 42-year-old woman remanded in custody on charges related to her son's death, died by hanging in her cell at Dame Phyllis Frost Centre on 24 July 2018. She had chronic suicidal ideation with periods of acute risk, was under regular psychiatric review, and was managed with appropriate risk ratings (S2 at time of death). The coroner found that mental health treatment was reasonable, risk assessments were comprehensive, and her management plan was regularly reviewed and adjusted. Custodial observations were conducted as required. No mental health staff review occurred on the day of death due to prison lockdown, but this was deemed reasonable as no concerning behaviours were noted. The coroner found no prevention opportunities and concluded the death was not preventable based on the available evidence and circumstances of care.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Drugs involved
Clinical conditions
Procedures
Contributing factors
- chronic suicidal ideation following son's death
- acute grief
- depressive illness
- auditory hallucinations
- access to ligature points in standard cell
- custodial environment stress
Full text
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