Deceased
JSZ
Demographics
66y, male
Coroner
Decision ofDeputy State Coroner Hosking
Date of death
2023-09-20
Finding date
2025-10-20
Cause of death
Multiple blunt force injuries
AI-generated summary
JSZ, a 66-year-old forensic patient with chronic paranoid schizophrenia, died by suicide while on unsupervised day leave from Cumberland Hospital's Bunya Unit on 20 September 2023. He jumped from a cliff at Queen Elizabeth Lookout in the Blue Mountains. Despite being assessed as low risk for self-harm before his departure, critical clinical opportunities were missed: his bag was not inspected (the Guidelines required attention to patient belongings), preventing discovery of a Note indicating premeditated intention and $500 cash; he was not adequately monitored during leave via required telephone check-ins; and his abscondment was not reported to police promptly. While the decision to grant unsupervised leave was appropriate based on available information, policy non-compliance represented lost opportunities to identify his increased risk. The hospital subsequently implemented significant improvements including staff training, bag checks, regular leave monitoring, and photographic verification procedures.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
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