Inquest into the death of Sean Leigh MacWilliam
Deceased
Sean Leigh MacWilliam
Demographics
16y, male
Date of death
2011-03-24
Finding date
2014-08-13
Cause of death
asphyxia due to hanging, self-inflicted, with aspiration of gastric contents as contributing factor
AI-generated summary
Sean MacWilliam, 16 years old, died by asphyxia due to hanging on 24 March 2011. He had been admitted involuntarily to an adult mental health facility (Chisholm Ross Centre) following a mental health crisis on 15 March 2011. After nine days, clinicians determined he no longer met involuntary detention criteria and granted extended leave with outpatient follow-up. However, inadequacies emerged in the discharge plan: parents were unclear about supervision expectations, the after-hours mental health line had no information about Sean's history, and police responders were unaware of his recent psychiatric admission. On the evening of release, when Sean requested to visit a friend and police initially promised but then declined transport, crisis management failed. Between his father's last sighting and mother's discovery 25 minutes later, Sean died. The coroner found the decision to grant leave appropriate but noted planning failures in crisis response, parental supervision clarity, and inter-agency information sharing.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- major depressive disorder with concurrent substance abuse
- recent relationship breakup
- inappropriate placement in adult mental health facility
- inadequate discharge planning
- unclear parental supervision expectations
- mental health line lacking clinical information
- police unaware of psychiatric admission
- failed promise of police transport
- impulsive response to disappointment
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