Deceased
JCS
Demographics
36y, female
Date of death
2020-08-29
Finding date
2023-12-01
Cause of death
plastic bag asphyxia
AI-generated summary
A 36-year-old woman with longstanding severe mental illness, including recurrent suicidal ideation and self-harm, died in custody at Dame Phyllis Frost Centre from plastic bag asphyxia on 29 August 2020. She was housed in a maximum security prison with appropriate psychiatric oversight, holding an S1 (immediate risk) classification at the time of death. She had access to plastic packaging and cord material from clothing purchased within the prison despite risk assessments. The coroner found that custodial and clinical staff provided a high standard of care in extraordinarily challenging circumstances, with appropriate risk management protocols followed. Independent reviews confirmed no individual caused or contributed to the death. The case highlights the tension between managing extreme suicide risk and maintaining quality of life within custodial restrictions.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Procedures
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Nathan James Taylor, aged 40, died in Port Lincoln Prison on 24 March 2022 while in custody pending trial on witness interference charges. He had significant medical history including infective endocarditis with tricuspi…
53y · Male·Hanging
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…
41y · Male·Ligature compression of the neck (hanging) and penetrating sharp force injury (s…
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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