Deceased
Brent Reker
Demographics
35y, male
Date of death
2019-12-12
Finding date
2025-07-04
Cause of death
Hanging
AI-generated summary
Brent Reker, a 35-year-old prisoner with extensive history of suicide attempts (including hanging, overdose, and self-harm), died by hanging in Forbes Unit at Ravenhall Corrections Centre on 12 December 2019, approximately 90 minutes after transfer from Moroka therapeutic unit. Critical failures included: (1) his detailed suicide and self-harm (SASH) history was not discussed during the decision to transfer him, despite being documented; (2) his SASH risk rating of S4 and previous serious suicide attempts were not communicated to Forbes staff; (3) his Individual Management File did not accompany him to Forbes; (4) the planned pre-transfer discussion with the psychiatrist was abandoned; (5) delayed response to discovery of barricade prevented timely access to cell. The coroner found the failure to consider SASH history during discharge planning was a fundamental oversight that prevented properly informed risk assessment and planning.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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