Coronial
WAother

Inquest into the Death of slater

Deceased

Evan Charles Slater

Demographics

28y, male

Date of death

2001-03-12

Finding date

2003-03-07

Cause of death

Ligature compression of the neck (hanging)

AI-generated summary

Evan Charles Slater, 28, died by ligature compression of the neck (hanging) in Cell D7, Unit 10 of Hakea Prison on 12 March 2001. He was on remand facing assault and restraining order breach charges stemming from domestic disputes with two partners. The coroner found he died by suicide. While Slater was assessed as at-risk of self-harm on admission and placed in the Crisis Care Unit, he was removed from the At Risk Management System on 5 February despite recommendations for continued monitoring pending court appearances. No follow-up assessment by the Forensic Case Management Team occurred after court dates on 6 and 16 February. On the evening of his death, Slater was distressed following a visit from one partner (Ms Mackay) and an inability to contact the other (Ms Narrier) before lockdown. The coroner identified gaps in follow-up care, inadequate communication regarding ongoing risk, and design features (accessible window bars) facilitating impulsive suicide. The coroner recommended continued review of FCMT recommendations, expedited review of window treatments in prison cells, and redesigned next-of-kin notification forms to accommodate Aboriginal cultural concepts of family.

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

Specialties

psychiatrycorrectional healthgeneral practice

Error types

communicationsystemdelay

Drugs involved

anti-depressant medication

Clinical conditions

depressionanxietysuicidal ideation

Contributing factors

  • Removal from At Risk Management System without comprehensive reassessment despite FCMT recommendation for continued monitoring
  • Lack of follow-up contact with Forensic Case Management Team after court appearances on 6 and 16 February 2001
  • Inability to communicate with partner (Ms Narrier) prior to lockdown on evening of death
  • Escalating anxiety regarding pending court appearance and likelihood of substantial prison sentence
  • Accessible window bars in cell providing obvious hanging point
  • Domestic relationship crisis with two partners and mounting personal distress
  • Restriction of officer-initiated telephone calls following 11 March incident

Coroner's recommendations

  1. Where an experienced FCMT professional has indicated a need for follow-up reviews, they should be carried out.
  2. The ongoing review of window treatments in prison cells should be expedited to reduce obvious accessible hanging points.
  3. The 'next of kin' form should be redesigned to accommodate Aboriginal cultural concepts of family and encourage prisoners to nominate multiple emergency contacts where appropriate.
Full text
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