Deceased
Adrian Nicholas Pitman
Demographics
54y, male
Date of death
2016-03-15
Finding date
2019-10-14
Cause of death
Multiple injuries due to motor vehicle collision with retaining wall caused by deceased with intention to end own life (suicide)
AI-generated summary
Adrian Pitman, a 54-year-old man with treatment-resistant schizophrenia, died by suicide following a motor vehicle collision with a retaining wall. He was subject to a psychiatric treatment order and had 33 different case managers since 2000, receiving care from AMHU, community mental health teams, and a clinical manager. Despite regular fortnightly medication reviews, monthly home visits, and multi-disciplinary meetings, his private suicidal intention was undetected. The coroner found no evidence of care contributing to his death and recognised clinicians appropriately applied the least restrictive approach given his refusal of residential rehabilitation. However, the coroner identified systemic concerns: his family was excluded from care planning despite supporting his accommodation; consistent case management was absent; and suicide risk questioning was infrequent due to his apparent stability. The coroner recommended family involvement in discharge planning procedures and consultation with his mother, emphasising balancing privacy rights with carer notification in chronic mental illness.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
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36y · Male·Drowning
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