Inquest into the death of WM

59y · Male·Hanging

A 59-year-old man serving a life sentence died by hanging in his segregation cell at Lithgow Correctional Centre on 2-3 April 2020. He had a history of depression, anxiety, and a prior serious self-harm attempt in 2010 requiring hospitalisation. Despite receiving psychiatric care and antidepressant medication (mirtazapine), he was not assessed as requiring close observation in the weeks before death. He appeared accepting of returning to mainstream population when segregation was revoked. Multiple hanging points existed in his cell including a metal grating above the door. While psychiatric support was deemed adequate, the coroner identified concerns about the availability of hanging points in correctional facilities and inadequate removal despite policy breaches (makeshift clothesline visible to staff). The death was self-inflicted but clinical escalation, risk reassessment timing, and environmental safety measures warrant review.