Coronial
NSWother

Inquest into the death of LP

Demographics

72y, male

Date of death

2016-01-12

Finding date

2017-07-11

Cause of death

multiple injuries resulting from catastrophic head injury with massive disruption of skull and facial bones, multiple rib fractures, complex pelvic fracture and multiple bilateral limb fractures

AI-generated summary

A 72-year-old man with schizophrenia and a history of suicidal ideation died by jumping from level 7 of a shopping centre. He had stopped taking prescribed medications and had been planning this action, making calls to family members beforehand stating his intention. Police negotiators arrived within minutes and attempted engagement, but the patient was determined. A trained nurse intervened without police direction, potentially creating confusion during negotiations. The police response was professional and timely. The death was not preventable given the patient's clear determination and short timeframe, but the case highlights risks of third-party intervention in active suicide negotiations and the importance of trained negotiators in mental health crises.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Contributing factors

  • schizophrenia with inadequate treatment adherence
  • cessation of psychiatric medications
  • previous history of suicidal ideation with specific plans
  • loss of supportive 'spirit guides' - perceived loss of coping mechanism
  • third person intervention during active police negotiation

Coroner's recommendations

  1. Case study involving third-party intervention during police suicide negotiation to be provided to Commander of Training and Education Command for possible inclusion in training programme to address the risks of uninvited third-person intervention in active negotiations
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