Coroner's Finding: Brown, Logan Reece

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INQUEST INTO THE DEATH OF LOGAN REECE BROWN [2025] SACC 36 Inquest Findings of his Honour State Coroner Whittle 27 November 2025

CORONIAL INQUEST Examination of the cause and circumstances of the death of a man who took his own life while on home detention bail. The inquest explored the adequacy of the mental health care afforded to him in the lead up to his death.

Held:

1. Logan Reece Brown, aged 25 years of Woodcroft, died at Woodcroft on 24 July 2021 as a result of hanging.

2. Circumstances of death as set out in these findings.

No recommendations made.

Counsel Assisting: MR D EVANS Hearing Date/s: 10/09/2025 Inquest No: 25/2025 File No/s: 1573/2021

This judgment contains discussion of suicide and may be distressing to some people There is always help available If you need support, contact Lifeline Australia Call 13 11 14 or Text 0477 13 11 14 or chat online at www.lifeline.org.au/crisis-chat Aboriginal & Torres Strait Islander Support Call 13YARN (13 92 76) Kids Helpline Call 1800 55 1800 MensLine Australia Call 1300 78 99 78

INQUEST INTO THE DEATH OF LOGAN REECE BROWN [2025] SACC 36 Introduction and background Logan Brown was born on 13 March 1996. He lived with his mother, Lisa Whamond, at Woodcroft. His father was Reginald Brown and he had a younger brother, Cameron.1 In primary school, Mr Brown did well. He was an A-grade student who won a scholarship to Tatachilla College but was not able to take it up as his family moved between Adelaide and Tasmania often.2 Around Year 6, his grades slipped to a D level. He finished school in Year 11 with an alternative pathway.3 Mr Brown reported to a psychiatrist that he began using cannabis and methylamphetamine at the age of 15.4 He reported to a psychologist that he had been using methylamphetamine from the age of 13, which fits with the change in his academic results.5 He continued relying on those drugs throughout life, with periods of abstinence of up to a year. He had some involvement with police in respect of minor offending.6 Mr Brown’s parents separated in 2016.7 After this, he got a job as a flooring contractor, setting up his own van and becoming successful. Ms Whamond observed that during the time he was working, Mr Brown’s involvement with police seemed to stop.8 Mr Brown reported that his relationships were tumultuous and that he never had a clear sense of who he is or what he wants.9 He reported that he never expected to have a long future and that he expected to die young.10 Mr Brown said that he had intermittent periods of low mood and that when he was happy, he was waiting for his next low period.11 Mr Brown’s mental health history Ms Whamond describes incidents of paranoia over the years which manifested in Mr Brown hiding weapons throughout the house.12 She also observed messages where acquaintances had made threats against Mr Brown.13 Since 2013, Mr Brown regularly attended a GP clinic at Happy Valley, Fountain Valley Medical Centre.14 On two occasions over the years, Mr Brown attended wanting help 1 Exhibit C22, page 30 2 Exhibit C10 at [25] 3 Exhibit C4a at [6] 4 Exhibit C10 at [14] 5 Exhibit C20 6 Exhibit C4a at [17]; Exhibit C23 7 Exhibit C4a at [23] 8 Exhibit C4a at [25] 9 Exhibit C10 at [17] 10 Exhibit C10 at [11] 11 Exhibit C10 at [18] 12 Exhibit C4a at [30]-[34] 13 Exhibit C4a at [31] 14 Exhibit C8a at [4]

[2025] SACC 36 State Coroner Whittle giving up drugs. He was given prescriptions for oxazepam to help him sleep without the aid of marijuana.15 On 26 December 2018, Mr Brown was taken to the Flinders Medical Centre after coming off his motorbike at speed and sliding along the road.16 His GP clinic managed the pain during his recovery.

In March 2019, Mr Brown was referred to Drug and Alcohol Services South Australia (DASSA) after he reported continuing issues with drugs and alcohol.17 At that stage, he said he had no suicidal thoughts. DASSA advised that Mr Brown never returned their call.18 In late May 2019, Mr Brown was involved in another motorbike accident. He sustained a shear fracture of his left tibia which required internal fixation at the Royal Adelaide Hospital.19 He was kept in hospital for four days.20 Following the accident, he sold his motorbike and used the $6,000 to buy drugs over the next few weeks. He pushed himself hard to recover so he could return to work quickly.21 On 16 August 2019, Mr Brown attended the GP clinic and saw Dr Tejveer Chaggar. He reported feeling anxious, but without suicidal thoughts or attempts.22 He transitioned from oxazepam to temazepam and Dr Chaggar prepared a Mental Health Care Plan which involved referral for cognitive behavioural therapy with a psychologist, Mr Radek Stratil.23 Mr Brown attended an appointment with Mr Stratil on 28 August 2019. He reported struggling with anger. He said that he had no suicidal thoughts recently but spoke about thoughts when he was younger.24 He reported that he felt like he had bipolar disorder. He said that he was eager to return to work, even against the advice of his physiotherapist, but that he would have staff to do work that he could not do himself because of his injury.

Mr Stratil made notes for himself about topics he wanted to explore further with Mr Brown and sent him away to complete a personality assessment prior to his next appointment.25 Mr Brown cancelled that next appointment and then never rebooked.

On 18 February 2020, Ms Whamond called the Mental Health Triage service, reporting concerns about Mr Brown’s drug use and behaviour. Police attended and found no grounds to convey Mr Brown for a mental health assessment.26 15 Exhibit C16, pages 6-7 16 Exhibit C16, page 55 17 Exhibit C16, page 7 18 Exhibit C16, page 57 19 Exhibit C10 at [24]; Exhibit C16, page 63 20 Exhibit C16, page 60 21 Exhibit C16, page 69 22 Exhibit C16, page 9 23 Exhibit C16, pages 23, 26 24 Exhibit C20 25 Exhibit C20 26 Exhibit C10 at [50]

[2025] SACC 36 State Coroner Whittle On 15 October 2020, Mr Brown was taken to the Emergency Department with a drug overdose. He was kept for a few hours and then sent home.27 On 22 December 2020, Mr Brown attended his GP clinic and saw Dr Simon Onyeizugbo.28 He told Dr Onyeizugbo that he was having a difficult time with his girlfriend, and he asked for a psychology referral. Dr Onyeizugbo made a Mental Health Care Plan and referred him to PsychMed.29 Mr Brown had poor engagement with PsychMed during this time but did report that his thoughts of wanting to hurt other people had disappeared and that he had no suicidal intent.

After a car accident while intoxicated, Mr Brown allegedly assaulted the elderly driver and passenger of the other car before using a tire iron to smash the windows and panels of that car.30 He reported that he drove home and forgot about the incident until police came to arrest him for aggravated assault and property damage.

On 25 January 2021 Mr Brown had a psychologist appointment which he did not attend.31 Mr Brown called the Mental Health Triage line on 26 January 2021.32 He said that he wanted help because he had noticed that he had been getting aggressive recently and that he was worried he would hurt himself or someone else. He described having taken an overdose of Panadol and serapax the previous night and being disappointed at having woken up. On 27 January 2021 he was reviewed over 90 minutes at Noarlunga GP Plus by a social worker, Samantha O’Flaherty.33 Ms O’Flaherty assessed Mr Brown’s suicide or self-harm risk at that time as being acute low to mild. He denied thoughts, plans or intent at the time of the assessment. Ms O’Flaherty recorded ‘Low acute exacerbation of chronic vulnerability risk due to current court proceedings and substance use’.34 His case was then reviewed at a Southern Adelaide Community Mental Health team meeting on 29 January 2021.35 It was noted that Mr Brown was seeking and engaging in services and that during assessment he had denied thoughts of suicidal intent or planning. It was recorded that he said he was ‘turning over a new leaf’. He was still considered to be low acute risk of suicide or self-harm.36 It was decided that he should be offered a review by Dr Champion, a very experienced psychiatrist.37 On 30 January 2021, Ms O’Flaherty spoke to Ms Whamond. Ms Whamond reported that Mr Brown had told her that he thought his assessment had gone well.38 Ms O’Flaherty then spoke to Dr Onyeizugbo. Mr Brown did not answer two calls from Ms O’Flaherty on this day.

27 Exhibit C16, page 73 28 Exhibit C16, page 11 29 Exhibit C16, page 35 30 Exhibit C10 at [13] 31 Exhibit C16, page 95 32 Exhibit C10 at [4] 33 Exhibit C22, pages 34-38 34 Exhibit C22, page 37 35 Exhibit C16, page 78 36 Exhibit C16, page 82 37 Exhibit C22, page 43 38 Exhibit C22, page 44

[2025] SACC 36 State Coroner Whittle On 31 January 2021, Ms O’Flaherty tried to contact Mr Brown but was not able to reach him or his mother.39 Mr Brown engaged with the Community Mental Health Team on 4, 9 and 12 February 2021. On 4 February 2021, he said that his mood was ‘pretty good’ and that working consistently had done wonders for his mental health.40 He reported that he was having a period of drug abstinence. He said that he still had a rage inside of him, but that he was channelling it into his work. He denied any desire to self-harm. On 9 February 2021, he again denied suicidal intention and desire to self-harm.41 The topic of DASSA was raised and Mr Brown said that he wanted to try to abstain from methylamphetamine on his own. He said, ‘I know within myself I can do it’. On 12 February 2021, Mr Brown said that he had not used methylamphetamine but had been on a ‘weed binge’. He again denied thoughts of self-harm and suicide.42 He said that his thoughts of wanting to hurt other people had disappeared.

Dr Andrew Champion, consultant psychiatrist with the Noarlunga Acute and Mood Specialist Mental Health Team, met with Mr Brown on 19 February 2021.43 Mr Brown reported issues with his relationship and that he experienced recurrent intense anger.

Dr Champion concluded that there was no evidence of any psychotic disorder but diagnosed polysubstance use disorder and borderline personality disorder. Dr Champion detected some antisocial traits and obsessional traits. He found no evidence of suicidal intent after asking Mr Brown about the topic, although he noted that there was a chronic history of suicidal ideation without planning, preparation or intent.44 Dr Champion educated Mr Brown in relation to borderline personality disorder and prescribed an offlicence trial of low dose quetiapine.45 Dr Champion encouraged Mr Brown to speak to his GP to obtain a Mental Health Care Plan for psychological therapy and drug counselling.46 Dr Champion then sent a letter on 19 February 2021 to Dr Onyeizugbo setting out what had happened.47 Between 22 February and 17 March 2021, clinicians from the Community Mental Health Team left nine voicemail messages for Mr Brown inviting contact, with no response.48 On 3 March 2021, Mr Brown was found by police on a train track behaving aggressively and erratically.49 He had injured his left ankle. He was taken to the Noarlunga Hospital.

He said that he was walking along the train tracks to get to the next station. He told police that he wanted to get to the next station and did not want to be hit by a train. He admitted that he had laid on the tracks but said this was to get the train to stop. He denied any thoughts of self-harm but said that he had tried to commit suicide a week prior. An ambulance was requested. Mr Brown told paramedics that he was frustrated with his 39 Exhibit C22, page 2 40 Exhibit C22, page 3 41 Exhibit C22, page 4 42 Exhibit C22, page 5 43 Exhibit C10 at [6]; Exhibit C22, page 7-8 and 10-11; and Letter from Andrew Champion dated 19 February 2021 44 Exhibit C10 at [10] 45 Exhibit C10 at [54] 46 Exhibit C10 at [58] 47 Exhibit C16, page 86-88 48 Exhibit C10 at [64]; Exhibit C22, pages 9-19 49 Sunrise Records, page 14

[2025] SACC 36 State Coroner Whittle recent diagnosis by Dr Champion and that he did not agree with it. Powers under sections 56 and 57 of the Mental Health Act were exercised by police, then paramedics and then hospital staff to require Mr Brown to be assessed in hospital.50 He was x-rayed and there was no ankle fracture. While in hospital, Mr Brown again denied any intention to self-harm.51 The hospital staff accessed Mr Brown’s assessment from 26 January 2021 and linked it to his notes for this presentation.52 That night, Mr Brown was assessed by Dr Jerry Delic.53 Dr Delic concluded that Mr Brown’s main concern was his acute intoxication, and he was unable to determine if there was an underlying mental health disorder. Dr Delic determined that there was a risk to self by misadventure and the care and control powers continued to be used to allow for an assessment once sober. The following morning, Dr Gareth Stone took over care.54 He recorded that he wondered if the incident was related to Mr Brown not wanting to attend court that day. Mr Brown denied feeling depressed and denied being suicidal or homicidal. Dr Stone discharged Mr Brown on the basis that there was no acute mental health issue.

On 6 March 2021, the Community Mental Health Team was able to speak to Ms Whamond who reported that Mr Brown was taking his quetiapine, which was ‘zonking him out’ and that she believed he was no longer at risk of suicide.55 On 18 March 2021, Mr Brown was arrested by police in respect of an alleged carjacking.

He was initially remanded in custody and then was granted home-detention bail on 26 March 2021. Given that his liberty was restricted, Mr Brown was in custody under the home-detention bail agreement. This was imposed by a Magistrate in respect of a serious offence. Mr Brown was therefore lawfully in custody.

On 20 March 2021, clinicians from the Community Mental Health Team made an unannounced visit to Mr Brown’s home as is routine when there is non-engagement.56 There was no one home and a letter was left inviting contact.57 The Community Mental Health Team closed the episode of care on 25 March 2021 after reviewing the case and Mr Brown’s progress, noting his mother’s advice that she was no longer concerned about suicide and becoming aware that Mr Brown was in custody at that point.58 In contrast to that assessment, Ms Whamond says that she observed Mr Brown’s mental health issues worsen since going on home detention.59 In his initial conversation with his assigned community correctional officer, Mr Brown said that he had been prescribed quetiapine, but that he had discontinued it because he 50 Sunrise Records at 16 51 Sunrise Records at 30 52 Sunrise Records at 31 53 Sunrise Records at 35 54 Sunrise Records at 34-35 55 Exhibit C10 at [64]; Exhibit C22, page 15 56 Exhibit C10 at [65] 57 Exhibit C22, pages 20 and 54 58 Exhibit C10 at [65]; Exhibit C22, pages 22-24 59 Exhibit C4, page 2

[2025] SACC 36 State Coroner Whittle felt it ‘wasn’t the right’ medication.60 He said that he had not made any further appointment to review the medication.

On 1 April 2021, Mr Brown attended for his home detention intake appointment at the Noarlunga Correctional Centre. During the appointment there was a discussion about Mr Brown re-engaging with his psychiatrist.61 A referral was made to OARS for drug and alcohol counselling. Mr Brown attended at OARS on 12 April 2021, then weekly or fortnightly thereafter.62 On 8 April 2021, he attended at the GP Clinic and saw Dr Dlair Zangane.63 He said that he had seen a psychiatrist who had put him on Seroquel. He asked for temazepam to deal with trouble sleeping. On 13 April 2021, he saw Dr Onyeizugbo again and asked that his Mental Health Care Plan be redrawn for him to continue seeing Dr Champion.64 This was done.65 Dr Onyeizugbo recorded that it took a long time to clarify what Mr Brown was after.

Mr Brown had a relationship which had lasted about nine months but was cut short when Mr Brown found out that his girlfriend had been unfaithful.66 His girlfriend then commenced a new relationship with a friend of Mr Brown. This appears to have had a significant impact on him.

Sometime in April 2021, Mr Brown spoke to his mother about suicide, telling her that he had received a message about hanging. He then pulled the neck of his jumper down and she saw what looked like rope marks around his neck.67 He then refused to get help.

Ms Whamond said that after this incident, Mr Brown’s behaviour improved. He applied to Flinders University to study business and he began reading business books.68 He moved his gym equipment from the back room of the house into the shed and began renovating the room.69 Mr Brown attended a GP appointment on 5 May 2021.70 This time he was seen by Dr Bolaton. He reported feeling anxious and irritable, with low self-esteem and poor sleep. He denied suicidal intent and was prescribed quetiapine again.71 The events leading to Mr Brown’s death On 8 May 2021, Mr Brown’s father, Reginald Brown, rang the Mental Health Triage service. He said that Mr Brown had tried to hang himself and that an ambulance had 60 Exhibit C5 at [7] 61 Exhibit C5 at [9] 62 Exhibit C5 at [12] 63 Exhibit C16, page 12 64 Exhibit C16, page 12 65 Exhibit C16, pages 33 and 37 66 Exhibit C4a at [39] 67 Exhibit C4a at [41] 68 Exhibit C4a at [43] 69 Exhibit C4a at [44] 70 Exhibit C16, page 13 71 Exhibit C7 at [4]-[6]

[2025] SACC 36 State Coroner Whittle already been called and were on their way.72 The South Australian Ambulance Service has advised that there is no record of attending on this occasion.

On 14 May 2021, Mr Brown called the Mental Health Triage service.73 He denied suicidal intent. On 15 May 2021, he saw Dr Onyeizugbo and was given a referral letter for Dr Angelos Giannakoureas.74 On 20 May 2021, he attended the GP clinic and saw Dr Chaggar.75 They discussed a letter received from Dr Champion setting out Dr Champion’s findings. Mr Brown said that he wanted to be referred to a doctor specialising in addiction, and a referral to Dr Henning was prepared.76 On 23 June 2021, Mr Brown was scheduled for an appointment with Dr Henning, however this did not eventuate for an unknown reason.77 On 24 June 2021, Mr Brown recommenced his employment.78 During a supervision appointment, Mr Brown described being in a situation where he was waiting for a psychiatric appointment and rang the Mental Health Triage service but was advised that they only assisted in cases of acute crisis and referred him to his GP, who he knew would refer him to a psychologist, not a psychiatrist.79 Following this appointment, Mr Brown advised Community Corrections that he had changed his GP clinic and that he had been referred to Dr Giannakoureas for an appointment on 8 July 2021.80 On 1 July 2021, Mr Brown told his corrections supervisor that he was ‘feeling good getting back into routine’.81 On 8 July 2021, Mr Brown’s appointment with Dr Giannakoureas proceeded. Mr Brown said that his girlfriend’s infidelity had angered him and made him aggressive.82 He told Dr Giannakoureas that he had previously thought about self-harm but had no ongoing intention. Dr Giannakoureas thought that Mr Brown’s carjacking incident may have been driven by a drug-related psychosis that had resolved.83 He considered that it was possible that there was an evolving chronic psychotic illness, such as schizophrenia, with vague early symptoms that were yet to become more obvious.84 Dr Giannakoureas saw no urgency in medicating Mr Brown and instead scheduled follow-up appointments.

On 23 July 2021, Ms Whamond was at home with Mr Brown. In the evening, Mr Brown heated a meal and went to his room. The following morning, Ms Whamond got up early and went to work. In the afternoon, she returned. She found a note on the kitchen bench 72 Exhibit C10 at [51] 73 Exhibit C10 at [51] 74 Exhibit C16, pages 13 and 39 75 Exhibit C16, page 13 76 Exhibit C16, page 41 77 Exhibit C5 at [15] 78 Exhibit C5 at [21] 79 Exhibit C5 at [17] 80 Exhibit C5 at [19] 81 Exhibit C5 at [21] 82 Exhibit C11 at [10] 83 Exhibit C16, page 96 84 Exhibit C11 at [20]

[2025] SACC 36 State Coroner Whittle which said ‘I left a video on your iPad. I’m so sorry!’.85 She went to the pergola and found Mr Brown hanging. She said that he was obviously dead.

Ms Whamond called for an ambulance which was dispatched about a minute later and arrived about six minutes later.86 Mr Brown was declared life extinct upon the paramedics’ arrival.87 He was 25 years old.

Ms Whamond then found a video on her iPad which depicted Mr Brown speaking to the camera, in the clothes that he was wearing when he died. In the video, he said: ‘Ever since I was a kid, I’ve felt a gaping hole and I’ve always tried to fill it with drugs, motocross or whatever fucking obsession I have and I am at that point now that there is nothing left to fill it.’ He expressed his love for his family and that he was sorry. He said that he did not want to drag his family through ‘the nightmare’ any longer. He said he did not want to go to prison for ten years and did not want to go to a psych ward. He acknowledged that he had a lot of potential, but he said, ‘What good is having all this potential if I’m not right up here, there is no amount of talking, therapy or medication that is going to fix me’. He said he had forced himself into a situation where he had no other choice but to kill himself.

He said he had found his peace and was okay with it. He said that he was supposed to lead the way, but instead that his younger brother was his inspiration. He said, ‘I’ve been fantasising about killing myself for as long as I remember’.

He said that he felt no one in the Health Department cared or listened or wanted to medicate him. He said there was no light at the end of the tunnel for him anymore and that he had to distract himself to get through the days. He said that he had ruined his life and had no one to blame but himself. He said there was something dark growing inside him since he was a little kid and that he had been using drugs to escape the fact that he does not want to be here. He said, ‘There is no doctor in the world that can fix the way I am feeling’.

He spoke of doing motocross as the only time he had been happy and been able to escape his mind. He said that the only thing that had stopped him taking his own life over the years was the thought of his mother coming home and finding him.

Cause of death A post-mortem examination was conducted by Professor Roger Byard, limited to an external examination and CT scan, together with toxicological analysis. Professor Byard found a parchmented ligature mark around the neck and no evidence of any other injury that could have caused or contributed to death. Professor Byard concluded that Mr Brown’s cause of death was hanging.88 Toxicological analysis revealed a blood alcohol concentration of 0.16% as well as the presence of methylamphetamine and its metabolite, diazepam and its metabolite, and cannabinoids.89 85 Exhibit C4, page 3 86 Exhibit C21 87 Exhibit C21 88 Exhibit C2a 89 Exhibit C3a

[2025] SACC 36 State Coroner Whittle Expert opinion Mr Brown’s case was reviewed by an independent expert psychiatrist, Dr Adam Brett.

Dr Brett concluded that Mr Brown’s history was consistent with borderline personality disorder. Dr Brett noted that Mr Brown had a number of stressors in the lead up to his death, including relationship breakdown, episodes consistent with drug-induced psychoses and serious criminal charges.

Dr Brett’s opinion is that Mr Brown’s mental health was comprehensively assessed, and the management plan formed was sensible, in particular the psychological treatment and counselling recommended and the medication prescribed.

Dr Brett explains that there would not have been any quick fixes for Mr Brown’s problems and that the standard approach in the circumstances is for psychosocial interventions, including psychological therapies, exercise, recreation and medication.

Dr Brett considers that there were risk factors for suicide including borderline personality disorder, previous suicidal behaviour, low mood, relationship problems, not being at work, legal issues, embarrassment, shame and a lack of hope. There was a role for COVID isolation as well.

Care provided by various general practitioners On numerous occasions Mr Brown appeared to report symptoms of anxiety. He was prescribed medication to deal with this issue. He was referred to drug counselling and to psychologists as issues were apparent. When he asked for psychiatric review, he was provided a referral. It is noteworthy that Dr Onyeizugbo noted that when he made the psychiatric referral, it took a long time to work out what Mr Brown was asking for. He may not have been forthright about raising the idea and might not have been fully candid about the depths of his issues. When Mr Brown asked for a referral to a different psychiatrist, this was also done. In my opinion, there can be no criticism of the manner in which the various general practitioners engaged with Mr Brown or the quality of their treatments.

Care provided by Noarlunga Acute Mental Health Services Mr Brown was promptly assessed after calling for help. The social worker spoke to his mother and his GP to obtain collateral information. She scheduled a psychiatric review.

She was reassured multiple times from multiple sources that the risk of suicide had passed. In my opinion, there can be no criticism of the work of this team, particularly the extensive efforts of Ms O’Flaherty.

Care provided by Dr Champion Dr Champion reviewed Mr Brown. He excluded psychotic disorders and made a diagnosis of borderline personality disorder. He gave Mr Brown education about borderline personality disorder and the primary role of psychological therapy. He commenced Mr Brown on an off-licence prescription of quetiapine to try to address Mr Brown’s anger and rumination. He made a plan to consider a trial of an SSRI drug if the quetiapine did not work. He discussed this with Mr Brown. Given that there was no psychotic disorder, Dr Champion did not consider there to be any indication for further

[2025] SACC 36 State Coroner Whittle psychiatric review. Nevertheless, Dr Champion directed that the Acute Team stay in contact for two weeks to facilitate the transfer of care to GP and psychologist.

Dr Brett considers that Dr Champion’s work was appropriate, comprehensive and evidence based. I agree. There can be no criticism of Dr Champion’s treatment of Mr Brown.

Care provided by Dr Giannakoureas Mr Brown was reviewed by a second psychiatrist at his own request. Given his insistence, it was appropriate for Dr Onyeizugbo to make the referral. At the review, Mr Brown had spoken of ‘odd thoughts’ but indicated that they had eased. Dr Giannakoureas detected no thought disorder. Mr Brown admitted that he had thought of self-harm but said that he no longer had any ongoing intention to hurt himself. Dr Giannakoureas said that he agreed with Dr Champion’s diagnosis but also left room for a role of illicit drugs in Mr Brown’s behaviour. Mr Brown reported that he was abstinent and so the risk of further psychiatric-type issues was thought to be low. Dr Giannakoureas also gave thought to an emerging schizophrenia but saw no urgency to commence medications at that point. Mr Brown agreed to have further appointments with Dr Giannakoureas and agreed to refrain from using drugs. Mr Brown was ‘quite cheerful’ at the end of the appointment.

Dr Brett considers that Dr Giannakoureas’ care was appropriate and consistent with the standard of care expected, although Dr Brett does consider that the letter Dr Giannakoureas sent to the GP could have been more prescriptive and could have made more recommendations for ongoing care. I make no criticism of the treatment provided by Dr Giannakoureas.

Preventability The closest Mr Brown came to actively foreshadowing his intent was the incident on the train tracks in March 2021. In respect of that incident, Mr Brown denied suicidal intent but was nevertheless detained for mental health assessment by police, then paramedics and then doctors at the hospital. He was discharged after a number of assessments including after he had sobered up and denying suicidal intent when sober. In light of that, I find that the care provided to him was reasonable. He was discharged with the ongoing care of the Community Mental Health Team in place and with a medication regime in place.

In the end, Dr Brett’s opinion is that Mr Brown’s death was not predictable. He explained that the management of people with borderline personality disorders is complex and difficult. While Mr Brown had risk factors for suicide, he never presented to professionals with acute suicidal issues, that is, occasions where he presented as a person who was actively trying to end his life as distinct from someone with a chronic level of suicidal ideation. While he may have benefitted from treatment, he did not engage with many services beyond initial appointments, if at all. He appeared to be focussed on obtaining medication for bipolar disorder, which he did not have. He appeared uninterested in therapies directed at treating his borderline personality disorder. Overall, Dr Brett opined that the health system can be difficult to navigate and that the result was that Mr Brown’s holistic needs were not met. That is, Mr Brown could have been better

[2025] SACC 36 State Coroner Whittle supported by the health system, but his death was not preventable if any individual had acted differently.

Conclusions Mr Brown died at Woodcroft on 24 July 2021. The cause of his death was hanging.

At the time of his death, as a person on home detention bail, Mr Brown was lawfully in the custody of the Chief Executive of the Department for Correctional Services (DCS).

He was appropriately managed in custody by his DCS community corrections officer.

Mr Brown had a long history of interaction with private and public system clinicians, who provided appropriate treatment, including during the period of his home detention.

Mr Brown’s death was not preventable.

I make no recommendations.

Keywords: Death in Custody; Home Detention; Suicide