Inquest into the Death of Tim Alan LOOKER

29y · Male·ligature compression of the neck (hanging)

Tim Looker, aged 29, died by suicide in Bunbury Regional Prison on 3 October 2023 by hanging from a bedsheet attached to a protruding bolt in his cell. Tim had ADHD diagnosed since childhood (previously prescribed dexamphetamine) and Type 2 diabetes (metformin), neither condition treated during his 99-day imprisonment. Key clinical lessons include: (1) prisoners with longstanding ADHD managed by stimulants in the community should have access to alternative long-acting stimulants in prison rather than no ADHD treatment; (2) initial nursing assessments should prompt further investigation of blood glucose readings in the borderline range, particularly when diabetes is disclosed; (3) administrative systems must ensure follow-up of requests for medical records from external providers; and (4) doctor admission assessments should occur within the mandated 90-day timeframe to allow patients to discuss mental health and medical concerns. While the coroner identified several missed opportunities, no adverse findings were made against individual clinicians, as Tim did not disclose his diabetes to health providers and no prior incidents had flagged bolts as ligature risks.