Deceased
Shane Nathan Roberts
Demographics
41y, male
Date of death
2019-06-24
Finding date
2023-12-21
Cause of death
Ligature compression of the neck (hanging)
AI-generated summary
Shane Nathan Roberts, aged 41, died by ligature compression (hanging) in Hakea Prison on 24 June 2019. He had pre-existing depression and anxiety treated with citalopram. A prison doctor referred him to the Mental Health Team (MHT) on 7 May 2019 when his anxiety markedly worsened; however, severe understaffing prevented assessment until after his death. The MHT operated with only 2-3 nurses per shift and a psychiatrist 4 days weekly for 130-150 acutely unwell prisoners. Critical missed opportunities included failure to follow up when he didn't attend appointments and a 4-week delay before MHT discussion. The coroner found the care provided was 'not satisfactory' due to systemic resource failures, not individual clinician error. Key lessons: prison mental health services require substantial additional resourcing; anxiety and depression in custodial settings require accessible early intervention; system failures rather than individual negligence often underpin preventable deaths; suicide remains unpredictable even with optimal care.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
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PE, aged 53, died by hanging in Parklea Correctional Centre on 3 February 2024, four days after entering custody for the first time on remand. The coroner found PE's death was self-inflicted at a time of emotional turmoi…
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Corey Desmond Devree, aged 41, died by suicide in Bunbury Regional Prison on 14 October 2024 through ligature compression of the neck and a self-inflicted stab wound to the chest. Key clinical and systemic lessons includ…
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