Dean Kieran Lauder, aged 22, died on 31 May 1998 at Canning Vale Prison by ligature strangulation (hanging) while in a punishment cell. He was serving a 7-day sentence for cannabis possession offences. He had a history of psychiatric concerns, including suicidal ideation detected in September 1997, which had resolved with psychological monitoring and medication review. On 31 May 1998, he requested sleep medication but was appropriately declined and showed no obvious distress. A prison psychologist who saw him daily reported him coping well. He died by hanging using a sheet tied to a light fitting. A suicide note was found. The coroner noted the deceased appeared pressured to smuggle heroin for a fellow prisoner and feared consequences if he could not deliver it. The coroner recommended: (1) a coded radio system to alert hospital staff to hanging emergencies without alarming inmates; (2) review of maximum penalty practices by Visiting Justices; and (3) recognition that light fittings have since been modified to prevent their use as hanging points.
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Specialties
psychiatrygeneral practice
Drugs involved
cannabisheroinbenzodiazepines
Clinical conditions
auditory hallucinationssuicidal ideation
Contributing factors
Separate confinement (punishment cell)
Pressure to smuggle heroin for another prisoner to whom deceased owed a debt
Fear of consequences if drugs not delivered
History of suicidal ideation in September 1997
Cannabis intoxication
Concerns about unfairness of punishment imposed
Coroner's recommendations
Develop a coded radio system so that hospital officers called to a hanging emergency can immediately recognise the situation and make an informed decision whether to bring a defibrillator, alerting them without openly referring to hanging and alarming prisoners
Review prisoner disciplinary procedures to examine whether maximum penalties provided under the Prisons Act 1981 are being routinely imposed and, if so, address the approach to imposing penalties for drug-related charges through legislative change, guidelines, or training of Visiting Justices in best practices
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