A coronial inquest has found that gaps in supervision and unrestricted access to ligature-making materials contributed to the death of Justin James Cordy, a 34-year-old man who died by suicide less than 24 hours after being admitted to the Alexander Maconochie Centre in February 2023. Coroner Lucinda Wilson also identified failures in police communication and mental health service availability in the days before his death.
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Lucinda Wilson
Coroner of the Australian Capital Territory