Coroner's Finding: BROWN Kunmanara

18y · Male·Hypoxic brain injury following cardiac arrest due to neck compression from hanging

An 18-year-old Aboriginal man died from hypoxic brain injury following cardiac arrest from hanging. He had a chronic petrol-sniffing habit and was acutely intoxicated on petrol when he hanged himself after a police incident. Police responded appropriately to both the initial assault incident and the fatal incident. Clinical lessons include: (1) recognition that volatile substance inhalation can cause acute behavioural disturbance presenting as psychiatric emergency; (2) the Mental Health Act 2009 provisions allowing assessment of persons with serious effects of substance abuse should be considered by police; (3) no equivalent of Northern Territory's Volatile Substance Abuse Prevention Act existed in South Australia for general application, limiting intervention options; (4) inter-jurisdictional coordination on transient individuals with substance abuse was inadequate; (5) mental health services need clear protocols for assessing and treating volatile inhalant effects rather than dismissing as purely substance abuse or anti-social behaviour.