Inquest into the Death of Suzzanne Denise DAVIS

47y · Female·ligature compression of the neck (hanging)

A 47-year-old woman remanded in custody at Melaleuca Women's Prison died by ligature compression of the neck (hanging) on 13 August 2020. Ms Davis had significant history of substance use, mental health issues, and prior self-harm attempts. While physical health care was adequate, mental health management had several missed opportunities: a mental health review recommended on 11 August was not performed; her court appearance on 13 August was not flagged as a 'date of interest' despite known stressors; and her non-attendance at a psychiatrist appointment scheduled for the day of death was not followed up. The coroner found she was appropriately placed in a non-fully-ligature-minimised cell, and that it was inappropriate to permit an inmate to assist with CPR. Key systemic issues included inadequate follow-up of mental health concerns and insufficient appointment oversight procedures.