Inquest into the Death of Barry Matt STUART
Deceased
Barry Matt STUART
Demographics
49y, male
Date of death
2013-11-16
Finding date
2017-03-07
Cause of death
ligature compression of the neck (hanging)
AI-generated summary
Barry Matt Stuart, a 49-year-old prisoner at Hakea Prison, died by suicide via ligature compression of the neck in November 2013. Critical clinical lessons include: (1) maintaining psychiatric continuity of care is essential for prisoners with psychotic symptoms and depression, particularly regarding medication decisions; (2) when psychiatric review is delayed, interim management should continue medications providing psychological benefit rather than allowing them to lapse; (3) antipsychotics prescribed without confirmed diagnosis require psychiatrist review before cessation; (4) sedative effects of medications may be therapeutically important even if the primary indication is uncertain. The death was preventable through timely psychiatric review and continued antipsychotic provision or alternative sedation until formal assessment occurred. Systemic failures included severe shortage of forensic psychiatry services and lack of interim medication protocols during psychiatrist unavailability.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- cessation of olanzapine without psychiatric review
- severe shortage of forensic psychiatry services in prisons
- delayed psychiatric appointment (scheduled 2 weeks post-death)
- psychological dependence on sedative effects of medication
- broken relationship with ex-partner
- depression and history of previous suicide attempts
- poor sleep on cessation of olanzapine medication
- lack of alternative sedation provided following medication cessation
- mental health nurse decision to cease medication in context of resource limitations
Coroner's recommendations
- Department of Corrective Services should invest significantly more resources in ensuring prisoners are given regular access to psychiatrists
- Overall emphasis should be placed on providing a more holistic approach to mental health care in prisons
- Mental health nurses should not make decisions about ongoing medication requirements without medical officer advice (GP or psychiatrist)
- GPs prescribing antipsychotics prior to psychiatric review should record a working diagnosis and continue medication until psychiatric review unless good indication to cease; if ceasing, documentation should be meticulous
- Department should develop a formal 'missed medication' or 'refusal of medication' policy providing clear procedures when prisoners refuse medication
- GPs engaged with prison health services should be encouraged to undertake extended mental health skills training
- Steps should be taken to deliver the full FTE consultant psychiatry required for appropriate coverage across prisons
Full text
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