Coronial
NSWcommunity

Inquest into the death of JF

Deceased

JF

Demographics

60y, female

Coroner

Decision ofDeputy State Coroner Pearce

Date of death

2024-02-12

Finding date

2025-11-03

Cause of death

multiple injuries

AI-generated summary

JF, a 60-year-old woman with recurrent major depressive disorder and a history of suicide attempts, died by suicide at Redhead Headland on 12 February 2024. Despite three prior psychiatric hospitalizations and documented previous visits to cliff locations contemplating jumping, she did not engage with psychiatric follow-up after discharge in April 2023. Her mood declined in the weeks before death, she resigned from work citing distress, and she visited Redhead Headland where she jumped from a 42.3-metre cliff while police attempted intervention. The coroner found police response appropriate, with proper mental health training, timely negotiator deployment, and appropriate non-restraint decisions given dangerous terrain and safety risks. Suicide deterrence measures have since been implemented at the location.

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

Specialties

psychiatrygeneral practiceemergency medicine

Error types

system

Drugs involved

mirtazapineescitalopramcitalopram

Clinical conditions

recurrent major depressive disorderadjustment disorder with depressed moodanxiety disordersuicidal ideation

Contributing factors

  • recurrent major depressive disorder
  • inadequate psychiatric follow-up after hospitalization
  • work-related stress and mood decline
  • previous suicide attempts at similar locations
  • lack of engagement with psychological support in community
  • stressors including illness of family and friends
Full text

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