Inquest into the Death of Ayumi KIMOTO
Deceased
Ayumi KIMOTO
Demographics
32y, male
Date of death
2010-03-21
Finding date
- 23 May 2014
Cause of death
ligature compression of the neck (hanging)
AI-generated summary
A 32-year-old Japanese-American freelance photographer died by hanging in prison custody while remanded for importing prohibited material. He was comprehensively assessed on admission by experienced prison reception and nursing staff and appropriately deemed not to be at immediate risk of self-harm, displaying calm demeanor and appropriate responses. He was housed with a peer support prisoner and appeared coping well initially. The death occurred during a brief unsupervised period when he was alone in his cell. While initial assessments were appropriate, the case highlights the challenging nature of predicting suicide risk in first-time prisoners experiencing acute shame and social consequences. The coroner emphasizes that prison infrastructure improvements (ligature minimization) may help prevent future deaths, though this particular death could not have been prevented by available assessment tools.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Contributing factors
- recent arrest and imprisonment
- cultural shame regarding criminal charges
- concern about media coverage and family consequences
- first-time prisoner anxiety
- access to ligature materials in cell
- extended unsupervised time alone in cell
Coroner's recommendations
- Hakea Prison Officers in Reception/Admission attend Suicide Prevention Gatekeeper training (all staff completed)
- Implement new ARMS-RIA reception intake assessment form replacing MR011 (rolled out state-wide March 2011)
- Continue ligature minimisation program with priority funding to retrofit older cells in unsecured areas
- Maintain cables within safe cells at maximum 30cm length (achieved by May 2013 compliance check)
- Prioritize funding for ligature minimisation works in non-secure cells to prevent future deaths by hanging
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