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.
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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
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