Inquest into the Death of Axel Josef CREMER
Deceased
Axel Josef CREMER
Demographics
58y, male
Date of death
2014-01-05
Finding date
2015-10-30
Cause of death
Methiocarb toxicity
AI-generated summary
A 58-year-old prisoner at Karnet Prison Farm died from intentional methiocarb pesticide ingestion (suicide). He had access to chemicals as part of his horticultural work role and was able to secrete methiocarb to his cell. The coroner found medical care satisfactory and supervision reasonable, given Karnet's minimum security status requiring unsupervised prisoner work for rehabilitation. No mental illness predisposing suicide was identified. The deceased showed no prior indication of suicidal intent and gave no warning signs. While chemical access posed a theoretical risk, the coroner found it balanced appropriately against rehabilitation objectives. The death was entirely attributed to the deceased's conscious, planned decision, not custodial failures or medical negligence.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Drugs involved
Contributing factors
- Access to pesticide chemicals in horticultural work role
- Ability to secrete chemicals to cell
- Divorce proceedings served 2 January 2014
- Despair over loss of contact with stepdaughters due to his criminal acts
Coroner's recommendations
- Upgrade of chemical store at Karnet undertaken to allow centralised storage and increase control of chemicals
- Priority Broadcast Directive (12 August 2014) prohibiting storage of cleaning chemicals of any description in cells
- Assistant Commissioner Custodial Operations Notice (16 September 2014) directing inspection and search of prisoners leaving work locations, cell inspections for contraband, and compliance with Hazardous Substances and Dangerous Goods Procedure
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