Inquest into the Death of Aaron Luke PRISGROVE

32y · Male·ligature compression of the neck (hanging)

Aaron Luke Prisgrove, a 32-year-old man with depression, alcohol abuse, and acromegaly, died by hanging on 12 July 2011, shortly after involuntary admission to Graylands Hospital's Smith Ward. He had presented to Tom Price Hospital on 8 July following a panadeine overdose, was transferred to Royal Perth Hospital where he made two hanging attempts, then transferred to Graylands. At Graylands, experienced nursing staff assessed him as high-risk but changed monitoring from one-to-one specialling to 15-minute observations based on his calm presentation. He was allowed to rest in a remote room while waiting for medical assessment. He hanged himself using his military holdall bag. The coroner found staff acted reasonably given circumstances, resources, and available policies, though hindsight reveals preventive steps (retaining the bag, maintaining one-to-one observation, keeping him in day area) could have been taken. Changes implemented post-death include transferring newly admitted patients at same observation level as transferring hospital.