Coroner's Finding: TURNER Troy Phillip

36y · Male·hanging

Troy Phillip Turner, aged 36, died by hanging in his prison cell on 2 September 2001 while on remand for serious domestic violence-related offences. The coroner identified several preventable failures: (1) Duty Supervisor Ken Cluse directed that Mr Turner not be cut down and resuscitation not be attempted, despite unclear signs of death and uncertain duration of hanging. The coroner found this decision inappropriate—resuscitation should have been attempted; (2) No after-hours medical staff were available at the prison, placing critical reliance on custodial officers' emergency response capacity; (3) Prison cell design provided easily accessible hanging points via shower cubicle fixtures; (4) Strapping material used in the prison industries area was accessible to prisoners. The coroner emphasised that while Mr Turner had shown depressive symptoms requiring monitoring, the immediate preventable factor was the failure to attempt resuscitation, which may have made the difference between life and death.