Finding into death of Daylon John Roeton

28y · Male·Hanging

Daylon Roeton, 28, died by hanging in a mental health seclusion room using a ligature made from blanket binding. He was admitted involuntarily after expressing suicidal ideation and paracetamol overdose. The coroner found three key deficiencies causally related to his death: (1) access to a blanket with edge binding that could be modified into a ligature, (2) door hinges used as a ligature point, and (3) impaired line-of-sight visibility in the seclusion room preventing staff from observing his actions. While the decision to seclude and observation frequency were reasonable, visibility limitations prevented early detection of self-harm. The hospital implemented remedial actions including blanket replacement, hinge modification, improved lighting, larger viewing windows, and policy changes for seclusion safety.