Inquest into the Death of Leon John Donaldson
Deceased
Leon John Donaldson
Demographics
20y, male
Date of death
2004-09-02
Finding date
2006-03
Cause of death
Ligature compression of the neck (hanging)
AI-generated summary
Leon John Donaldson, a 20-year-old sentenced prisoner with a documented history of self-harm, depression, and suicidal ideation, died by hanging in his cell at Casuarina Prison on 2 September 2004. He had been identified as at chronic risk of self-harm and was receiving mental health support. Critical failures in his care included: (1) reception staff at Hakea Prison failing to identify and alert to a recent suicide attempt in police custody despite accompanying paperwork; (2) placement in a cell with obvious hanging points (shelving brackets) despite known chronic self-harm risk; and (3) cell checks not conducted according to protocol, with the evening check occurring during medication rounds, reducing effectiveness. The coroner found the death was suicide and made recommendations to urgently address cell ligature points, ensure appropriate alert systems are used, and notify external visitors of deaths in custody.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- Placement in cell with obvious hanging points (shelving brackets and unsecured shelves)
- Failure to identify and alert to recent suicide attempt in police custody at reception
- Cell checks not conducted according to protocol; evening check conducted during medication round rather than at separate time
- Known chronic risk of self-harm due to severe borderline personality disorder, impulsivity, and poor coping strategies
- Prisoner left alone in cell without checks after 9:00pm
- Distressing personal circumstances including custody concerns and relationship issues
Coroner's recommendations
- Department of Justice (Corrective Services) to urgently ensure sufficient cells without obvious hanging points are available for prisoners known to be at chronic risk of self-harm
- Cell check procedures must be reviewed and enforced to ensure evening checks are not conducted simultaneously with medication rounds, in accordance with Local Order
- Reception and medical staff training to be enhanced to ensure alerts from AIMS and police paperwork are properly identified and entered into TOMS system
- Death in Custody Incident Report forms must be readily accessible on TOMS to ensure proper documentation and identification of issues
- Visitor notification system to be implemented: when a death in custody occurs, visits book should be checked and intending visitors who have not been informed should be advised of the death
Full text
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