Deceased
Subash Subedi
Demographics
26y, male
Coroner
Decision ofDeputy State Coroner Ryan
Date of death
2018-02-14/2019-04-30
Finding date
2024-01-30
Cause of death
Not able to be determined - skeletalised remains
AI-generated summary
Subash Subedi, a 26-year-old international student from Nepal, died in a stormwater drainage system beneath the M2 Motorway between February 2018 and April 2019. He presented to Westmead Hospital ED on 14 February 2018 with acute mental health symptoms, including disorientation and dehydration following cannabis use and a period of erratic behaviour. He was briefly assessed by nursing staff but discharged without psychiatric review. Community mental health follow-up was arranged but failed due to inability to contact him (no phone, no contact details provided). His behaviour subsequently deteriorated, and he disappeared the same day. The coroner could not determine cause or manner of death due to skeletal remains. Clinical lessons include the importance of ensuring adequate psychiatric assessment before discharge for acutely unwell patients, obtaining reliable contact information, and ensuring safe follow-up arrangements, particularly for vulnerable international students in crisis.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
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