Finding into death of Daylon John Roeton
Deceased
Daylon John Roeton
Demographics
28y, male
Coroner
Coroner Kate Despot
Date of death
2020-03-17
Finding date
2023-09-15
Cause of death
Hanging
AI-generated summary
Daylon Roeton, 28, died by hanging in a mental health seclusion room using a ligature made from blanket binding. He was admitted involuntarily after expressing suicidal ideation and paracetamol overdose. The coroner found three key deficiencies causally related to his death: (1) access to a blanket with edge binding that could be modified into a ligature, (2) door hinges used as a ligature point, and (3) impaired line-of-sight visibility in the seclusion room preventing staff from observing his actions. While the decision to seclude and observation frequency were reasonable, visibility limitations prevented early detection of self-harm. The hospital implemented remedial actions including blanket replacement, hinge modification, improved lighting, larger viewing windows, and policy changes for seclusion safety.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- Impaired line-of-sight visibility in seclusion room due to mirror size, viewing window location, and warm lighting
- Access to blanket with edge binding capable of being modified into a ligature
- Narrow edge door hinges not identified as ligature risk in previous audits
- Delay in accessing seclusion room to allow time for additional security to arrive (2-3 minutes)
- Underlying suicidal ideation and acute mental health crisis
- Substance use including methamphetamine and paracetamol overdose
Full text
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.