Coronial
VICother

Finding into death of Travis Thomas Young

Deceased

Travis Thomas Young

Demographics

42y, male

Date of death

2019-09-30

Finding date

2022-02-01

Cause of death

hanging

AI-generated summary

A 42-year-old prisoner with generalised anxiety disorder and chronic tinnitus causing significant distress died by suicide while incarcerated. In the months preceding his death, he presented repeatedly to health staff reporting difficulty coping with tinnitus symptoms and requesting specialist referral. Days before death, he disclosed suicidal ideation to fellow prisoners, including specific mention of jumping from a railing. These disclosures were not reported to prison staff. He was awaiting ENT specialist appointment at the time of death. Key clinical lessons: recognise tinnitus-related psychological distress as a suicide risk factor; ensure comprehensive mental health risk assessment when prisoners express ongoing distress; establish clear protocols for prisoner-to-staff reporting of concerning statements; coordinate timely specialist referrals; document and escalate suicidal ideation expressed to any staff member.

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

Contributing factors

  • generalised anxiety disorder
  • chronic tinnitus causing emotional distress
  • insomnia and poor sleep
  • suicidal ideation not reported by other prisoners to staff
  • delayed ENT specialist referral
  • no documented suicide/self-harm risk rating despite mounting psychological distress

Coroner's recommendations

  1. Corrections Victoria confirm with each prison location that local policies or procedures ensure an intervention knife is carried by relevant staff when responding to incidents
  2. Systemic improvements to ensure clarity and consistency of 'at risk' referrals (as detailed in Justice Health report)
  3. Strengthen system-wide sentence progression processes where delegations are in place
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