Deceased
RC
Demographics
53y, male
Date of death
2014-04-15
Finding date
2017-02-28
Cause of death
Gunshot wound to the head
AI-generated summary
RC, a 53-year-old man with longstanding depression, died by suicide on 15 April 2014. He was under care of Campbelltown Community Mental Health (CoMHET) when a critical clinical failure occurred: a handwritten progress note documenting a suicide note found at his home was misplaced and not available during his psychological assessment the next day. Although RC denied suicidal ideation to the clinician, he had reportedly told his brother that suicide remained an option, was drinking heavily, had stopped lithium, and a suicide note had been found. Expert evidence indicated that a face-to-face senior clinician assessment on the evening of 14 April would have been preferable to telephone contact alone, given the combination of risk factors. The coroner found the care fell short of ideal practice, though acknowledged clinical guidelines allow for discretion. Key failures included loss of critical documentation and inadequate escalation of risk.
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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