Mr Deleman was a 69-year-old man with untreated schizophrenia, advanced liver cirrhosis, and hepatitis C, presenting to hospital on 1 April 2024 with abdominal swelling. He was admitted to The Canberra Hospital and placed on a Psychiatric Treatment Order on 15 April 2024. Despite receiving appropriate psychiatric and medical care during his admission, he developed peritonitis secondary to large bowel perforation, complicated by Clostridium bacteraemia and hepatocellular carcinoma. He was transferred to ICU on 4 May 2024 and died on 9 May 2024. The coroner found no shortfalls in the quality of his psychiatric or medical care and noted his death fit an epidemiological pattern of early mortality in people with severe mental illness combined with physical comorbidities, malnutrition, and substance abuse.
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