Inquest into the death of Michael

28y · Male·In keeping with Hanging

A 28-year-old man with a history of depression, anxiety, and previous self-harm died by hanging during a police response to a domestic violence incident. Police attended after his sister reported he had breached an ADVO while intoxicated and assaulted his partner. Officers made a conscious decision not to immediately arrest him, instead conducting formal interviews with witnesses before searching for him. The deceased left the house undetected and died by suicide in a remote shed on the property. Although the deceased had texted his sister at 9.02am stating he had a noose around his neck, police were unaware of any suicide risk at the time and conducted their response appropriately according to policy. Key lesson: the CAD system provided confusing merged messages that obscured the situation, and paramedics did not identify suicide risk during their earlier assessment, despite being called for a mental health evaluation.