Deceased
Timothy Darryl Casey
Demographics
29y, male
Date of death
2008-03-28
Finding date
2012-09-21
Cause of death
hanging
AI-generated summary
Timothy Casey, 29, charged with murder, died by hanging in Port Phillip Prison on 28 March 2008, 12 days after arrival. His death resulted from systemic failures in psychiatric assessment and care. At Melbourne Assessment Prison, Nurse T D assigned Casey a P3 rating despite six previous suicide attempts, substance abuse, and schizophrenic symptoms. After self-harm on 29 February, registrar Dr S T urgently requested psychiatric consultant Dr A W review Casey for possible admission to the Acute Assessment Unit, but Dr A W never saw him. Without proper psychiatric review, Casey's suicide risk was downgraded to P2 on 16 March despite Nurse T D noting he was 'thought disordered' and 'disassociated.' Meaningful observations were removed. Critical HRAT documentation failed to transfer to Port Phillip Prison. The coroner identified failures in psychiatric assessment, communication, and systemic reliance on non-clinically registered psychologists for suicide risk assessment. Proper escalation, continued observations, and complete medical record transfer might have prevented this death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
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Source and disclaimer
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