Coroner's Finding: CARTWRIGHT Stephen Andrew

51y · Male·Hanging

Stephen Cartwright, a 51-year-old psychologist, was arrested for breach of bail and died by hanging in police custody at Christies Beach Police Station. He displayed multiple risk factors including depression requiring medication, alcohol intoxication, agitation, and isolation from family. The charging sergeant refused his requests for medication and telephone contact with relatives, and failed to recognize him as at-risk despite standing orders requiring close monitoring of prisoners placed in single cells. Critically, no physical welfare checks were conducted during the 7-hour period following his placement in the cell. The coroner identified failures in prisoner supervision, inadequate CCTV monitoring, use of unsafe tear-able blankets, open cell doors as hanging points, and systemic failures in applying basic custody procedures. The death was preventable had officers properly assessed risk and conducted required monitoring.