Coronial
NSWhome

Inquest into the death of Michael

Deceased

Michael

Demographics

28y, male

Coroner

Decision ofJudge Baptie

Date of death

2022-02-04

Finding date

2026-04-21

Cause of death

In keeping with Hanging

AI-generated summary

A 28-year-old man with a history of depression, anxiety, and previous self-harm died by hanging during a police response to a domestic violence incident. Police attended after his sister reported he had breached an ADVO while intoxicated and assaulted his partner. Officers made a conscious decision not to immediately arrest him, instead conducting formal interviews with witnesses before searching for him. The deceased left the house undetected and died by suicide in a remote shed on the property. Although the deceased had texted his sister at 9.02am stating he had a noose around his neck, police were unaware of any suicide risk at the time and conducted their response appropriately according to policy. Key lesson: the CAD system provided confusing merged messages that obscured the situation, and paramedics did not identify suicide risk during their earlier assessment, despite being called for a mental health evaluation.

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

Specialties

emergency medicineparamedicinegeneral practicepsychiatryforensic medicine

Error types

systemcommunication

Drugs involved

venlafaxinemirtazapinedesvenlafaxinealcoholcannabis

Clinical conditions

depressionanxietyself-harm historysuicidal ideationalcohol intoxicationcannabis use

Contributing factors

  • history of depression and anxiety
  • previous self-harm and suicide attempts
  • acute intoxication with alcohol and cannabis
  • relationship conflict and domestic violence incident
  • police attendance and threat of arrest
  • CAD system confusion regarding informant and persons of interest
  • paramedics did not identify suicide risk during assessment
  • deceased undetected departure from house during police interview process
Full text

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