Coronial
WAother

Inquest into the Death of Jordan Robert ANDERSON

Deceased

Jordan Robert ANDERSON

Demographics

23y, male

Coroner

Coroner Urquhart

Date of death

2017-03-23

Finding date

2020-12-22

Cause of death

hypoxic brain injury and bronchopneumonia complicating ligature compression of the neck

AI-generated summary

Jordan Robert Anderson, 23, died by suicide in Hakea Prison through ligature compression of the neck. Critical delays occurred when he was discovered unresponsive: 3 minutes 40 seconds elapsed before his cell door was unlocked, and 9 minutes 50 seconds before CPR commenced. Systemic issues included: prison health staff were not notified when Anderson received punitive confinement on 2 March 2017; no mental health assessment was conducted after his agitated behaviour in the exercise yard on 4 March; the standard cell was not ligature-minimised despite scheduled renovations; and prison officers held a mistaken belief that three officers were required before unlocking cells for medical emergencies. Since his death, the Department has improved protocols for night-shift medical emergencies, established better cell unlocking procedures, and upgraded ligature-minimisation in some cells. Clinical lessons include: ensuring timely mental health assessment after behavioural crises in custody, not delaying CPR initiation for additional tests, and ensuring adequate ligature-minimised cells.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

emergency medicinecardiologyforensic medicinecorrectional healthpsychiatry

Error types

proceduralcommunicationsystemdelay

Clinical conditions

suicide by hangingcardiac arresthypoxic brain injurycerebral ischaemiapulmonary oedemapneumoniabrain death

Procedures

cardiopulmonary resuscitationdefibrillationmechanical chest compression

Contributing factors

  • delay in unlocking cell door (3 minutes 40 seconds from Code Red emergency call)
  • delay in commencing CPR (9 minutes 50 seconds after discovery of unresponsiveness)
  • failure to conduct mental health assessment following violent behaviour incident on 4 March 2017
  • failure to notify prison health staff of punitive confinement order on 2 March 2017
  • prison staff mistaken belief that three officers were required to unlock cell during medical emergency
  • cell not ligature-minimised despite scheduled renovations
  • delay in calling ambulance (at least 7 minutes after Code Red emergency)
  • inadequate number of safe cells at facility
  • insufficient mental health staff availability for 24/7 assessment

Coroner's recommendations

  1. As a matter of urgency, the Department should increase the number of ligature minimised cells at Hakea Prison with a view to having all cells either fully ligature minimised or three-point ligature minimised as soon as possible
  2. The Department should increase the number of safe cells from six to 12 in order to better manage prisoners and enhance security at Hakea Prison
  3. A suitably qualified prison mental health staff member should conduct a mental health assessment as soon as practicable upon any prisoner who has been involved in a critical incident regarding violent behaviour or who has been subject to punishment requiring placement in a specialised unit for disciplinary purposes
  4. Prison officers should participate in drills involving simulated hanging scenarios during initial employment training and during refresher training for CPR to better equip them to deal with situations where prisoners attempt suicide by hanging
Full text
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