Deceased
Jayke Michael Aleckson
Demographics
24y, male
Date of death
2018-10-15
Finding date
2024-12-11
Cause of death
Hypoxic Ischaemic Encephalopathy due to hanging
AI-generated summary
Jayke Aleckson, 24, died by hanging in a non-BDRP compliant prison health cell while on remand at Marngoneet Correctional Centre in October 2018. Key clinical lessons: (1) Multiple unmet requests for antidepressant medication despite documented depression history and clear clinical indication—a significant departure from reasonable care standards; (2) Failure to reschedule or rebook psychiatric appointments upon prison transfers, breaking continuity of mental health care; (3) Inadequate risk assessment prior to placement in a non-compliant cell despite T3 vulnerability rating and separation status; (4) Poor documentation quality in mental health records limiting clinical decision-making; (5) System failures in information transfer between prison health providers. Earlier medication initiation and proper psychiatric assessment would have been clinically appropriate, though unlikely to have prevented the impulsive act. The coroner emphasised need for structured handover at transitions, documented risk assessment processes, and ensuring separated prisoners are placed only in BDRP-compliant cells.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
40y · Male·Unascertained
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36y · Male·Drowning
Gary Dale Sargeant, a 36-year-old Royal Australian Air Force member, died by drowning after absconding from Edinburgh Health Centre during an acute mental health crisis. Critical clinical failures included: a clinical ps…
44y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest in the setting of p…
Elizabeth Ferris, a 44-year-old woman with schizoaffective disorder and polysubstance use disorder, died from hypoxic ischaemic encephalopathy following cardiac arrest in the setting of presumed drug toxicity. She was fo…
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