Demographics
39y, male
Date of death
2017-12-28
Finding date
2020-11-16
Cause of death
Self-inflicted death by hanging
AI-generated summary
A 39-year-old man with longstanding Bipolar I Disorder died by hanging on 28 December 2017, shortly after police attended a domestic disturbance at his mother's home. He had expressed suicidal ideation to his treating psychiatrist on multiple occasions, specifically mentioning hanging from a shed structure. On the day of death, he made suicidal statements during an argument and texted his estranged wife farewell messages. Police attended but assessed him as low-risk after he minimised his suicidal threats, claiming he was 'just venting'. He denied current suicidal intent and stated he was taking medication for bipolar disorder. Police departed after 15 minutes; he died within minutes thereafter. Expert evidence indicated the police assessment was inadequate. Critical information about his specific suicide method ideation and psychiatric history was unknown to responding officers. The coroner found insufficient mental health training, lack of access to medical records, and inadequate risk assessment contributed to the failure to escalate care or arrange mental health assessment.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
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36y · Male·Drowning
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Source and disclaimer
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