Deceased
AB
Demographics
33y, male
Date of death
2013-04-20
Finding date
2015-05-22
Cause of death
Multiple injuries sustained from falling from height (fifth-floor window ledge) at Liverpool Hospital
AI-generated summary
AB, a 33-year-old male, died on 20 April 2013 after falling from the fifth-floor window ledge of Liverpool Hospital while under police negotiation. He had been transferred from prison to immigration detention on 9 April 2013, facing deportation to Papua New Guinea. Key clinical lessons: (1) Medical records transfer between correctional facilities and immigration detention requires formal systems to ensure continuity of care—AB's ongoing Quetiapine medication was unknown at VIDC; (2) Mental health assessment conducted under restrictive security conditions (guards present, through cell door slots) was inadequate and could not identify psychological distress; (3) Communication failures between agencies (Serco, IHMS, Hospital, Police) affected coordinated risk management; (4) Preventability is uncertain—while comprehensive psychiatric assessment might have identified vulnerability, the coroner found no evidence AB presented as suicidal before 19 April 2013. The police negotiation was expertly conducted but could have considered hypothermia risks and medical consultation in extended standoffs.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
36y · Male·Drowning
Gary Dale Sargeant, a 36-year-old Royal Australian Air Force member, died by drowning after absconding from Edinburgh Health Centre during an acute mental health crisis. Critical clinical failures included: a clinical ps…
45y · Male·focal coronary artery disease and cardiomegaly
Stratos Ioannidis, age 45, died at Maroondah Hospital on 28 March 2025 from focal coronary artery disease and cardiomegaly during an involuntary psychiatric admission. He presented with acute psychosis from bipolar disor…
59y · Male·Multiple injuries
Martin Carl Quiterio, a 59-year-old man with longstanding schizophrenia and suspected autism spectrum disorder, died on 3 January 2024 when he jumped from the 14th floor of a car park in West Perth. He had been discharge…
Source and disclaimer
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