Coronial
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Inquest into the Death of Stephen Kenneth SHERWOOD

Deceased

Stephen Kenneth SHERWOOD

Demographics

31y, male

Date of death

2022-04-13

Finding date

2024-09-11

Cause of death

ligature compression of the neck (hanging)

AI-generated summary

Stephen Sherwood, a 31-year-old Aboriginal man with untreated mental health issues and history of methylamphetamine use, died by suicide on 13 April 2022. He had attempted suicide by wrist-cutting on 30 March 2022 and threatened suicide on 4 April 2022, both resulting in police welfare checks. On 12 April 2022, two probationary constables attended a family violence complaint and served a Police Order. Although Stephen's sister and partner disclosed suicidal concerns and he had missed a mental health appointment, the officers did not contact the Mental Health Emergency Response Line (MHERL) for guidance after receiving this information. The coroner found this was a missed opportunity but not a direct cause of death, as Stephen showed no overt signs of current distress and suicide risk remained unpredictable. The coroner criticised ongoing deployment of inexperienced probationary constables without adequate supervision.

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

Contributing factors

  • untreated mental health issues
  • undiagnosed depression
  • methylamphetamine use
  • childhood trauma
  • history of self-harm and suicidal ideation
  • missed mental health appointment on day of death
  • family violence stress
  • lack of ongoing mental health treatment despite recent referral
  • missed opportunity to contact MHERL after disclosure of suicidal concerns

Coroner's recommendations

  1. Western Australian Police Force to reconsider the rostering guideline proposed in June 2024: that probationary constables performing operational duties without experience in another jurisdiction be partnered with a police officer with at least nine months of post-probationary operational experience
  2. Greater attention to mental health screening protocols when police conduct welfare checks or attend incidents involving individuals with known mental health history
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