Inquest into the Death of Suzzanne Denise DAVIS
Deceased
Suzzanne Denise DAVIS
Demographics
47y, female
Coroner
Coroner Jenkin
Date of death
2020-08-13
Finding date
28 Mar 24
Cause of death
ligature compression of the neck (hanging)
AI-generated summary
A 47-year-old woman remanded in custody at Melaleuca Women's Prison died by ligature compression of the neck (hanging) on 13 August 2020. Ms Davis had significant history of substance use, mental health issues, and prior self-harm attempts. While physical health care was adequate, mental health management had several missed opportunities: a mental health review recommended on 11 August was not performed; her court appearance on 13 August was not flagged as a 'date of interest' despite known stressors; and her non-attendance at a psychiatrist appointment scheduled for the day of death was not followed up. The coroner found she was appropriately placed in a non-fully-ligature-minimised cell, and that it was inappropriate to permit an inmate to assist with CPR. Key systemic issues included inadequate follow-up of mental health concerns and insufficient appointment oversight procedures.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- inadequate mental health review and follow-up on 11 August 2020
- court appearance on 13 August not flagged as date of interest
- non-attendance at psychiatrist appointment not followed up
- cell not fully ligature minimised
- gaps in communication between custodial and mental health staff
- lack of proactive follow-up when prisoner failed to respond to appointment announcements
- prior mental health needs and history of self-harm not adequately escalated
Coroner's recommendations
- The Department should, as a matter of utmost urgency, undertake remedial work at Melaleuca Women's Prison to ensure that all cells are fully ligature minimised
- The Department should undertake an immediate audit of bunkbeds in all cells at Melaleuca Prison to ensure that these structures are fully ligature minimised
- The Department should remind custodial staff (by way of a Commissioner's Notice or other appropriate method) that prisoners are not to be asked or permitted to assist with an emergency response to another prisoner, except in exceptional circumstances
- The Department should consider ways in which dates of interest (DOI) for prisoners who are not being managed on the At Risk Management System (but who have nevertheless been identified as requiring additional support) can be flagged, so as to ensure that these prisoners can be followed up by staff before and after the DOI
Full text
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