Finding into death of Jeremy Edward Chandler

49y · Male·Acute blood loss from a single incised injury to left forearm

Jeremy Edward Chandler, a 49-year-old first-time prisoner, died by suicide in Melbourne Assessment Prison 36 hours after admission. He had been convicted of serious charges and remanded in custody pending sentencing. Despite meeting multiple criteria for at-risk assessment, his psychiatric evaluation documented his self-harm risk as "not known" rather than clearly identifying emerging risk. No formal follow-up assessment occurred during the critical first 72 hours—the highest-risk period for prison suicides. The coroner identified that adjustment issues and stress from his predicament likely manifested over this short timeframe but were not monitored. While immediate risk assessment tools were adequate, ongoing risk assessment processes failed. The coroner recommended formal follow-up assessments within 24 hours for first-time prisoners with documented risk factors assessed as "unknown" risk, and suggested further research on restricting razor access for new prisoners, though logistical challenges in mainstream population management were acknowledged.