Inquest into the death of H P
Deceased
HP
Demographics
52y, male
Date of death
2016-12-09
Finding date
2018-12-13
Cause of death
Multiple blunt force injuries from a fall from height
AI-generated summary
A 52-year-old man with paranoid schizophrenia subject to a Community Treatment Order died from injuries sustained after jumping from a third-floor balcony during enforcement of the order. Mental health workers and police attended his unit to administer depot antipsychotic medication following breach of the CTO. The deceased had made threats to jump if forced to take medication, but this critical information failed to reach attending police due to documentation error by a 000 operator. While police appropriately did not restrain the deceased based on his apparent compliance and changed demeanor after entry to the unit, the failure to communicate the suicide threat represents a significant communication breakdown. The coroner found the deceased was incapable of forming suicidal intent due to active psychosis at the time of death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- Paranoid schizophrenia with active psychosis
- Non-compliance with antipsychotic medication
- Failure to communicate threat to jump to attending police
- Inadequate risk assessment information provided to Acute Care Service team
- Human error in 000 CAD message recording by Senior Constable Lambert
- Incomplete information transfer between mental health services regarding suicide threats made at tribunal hearing
Coroner's recommendations
- A copy of these findings be forwarded to the Commander, Leichhardt Local Area Command. Appropriate education and training of police officers in that Command should take place regarding their statutory powers under sections 59 and 81 of the Mental Health Act 2007.
- Sydney Local Health District to continue updating procedures to clarify what documentation constitutes a 'recent assessment document' required for handover to ACS team for breach actions.
- Sydney Local Health District to continue review and update of the Home Visit Safety Checklist to ensure additional risk factors are appropriately recorded including historical risk events and suicide threats made during legal proceedings.
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