Deceased
DB
Demographics
28y, male
Date of death
2009-04-21
Finding date
2012-04-17
Cause of death
ligature strangulation
AI-generated summary
DB, a 28-year-old with first episode psychosis, was admitted to Nepean Hospital on 31 March 2009 after self-harming. He was appropriately diagnosed and treated with olanzapine under the Mental Health Act. Two independent psychiatrists confirmed his clinical care, medication, supervision, and leave decisions were appropriate. However, the coroner identified critical gaps: risk assessments at weekly interdisciplinary meetings were poorly recorded—one completed by a social worker who had never met DB—and the family received inadequate psycho-education about suicide risk and supervision requirements specific to early psychosis. When granted leave on 21 April, DB absconded, purchased rope, and died by ligature strangulation. The coroner recommended developing standardised leave forms and information packages for first episode psychosis patients, emphasising formal family education on diagnosis, treatment, heightened suicide risk, and supervision requirements.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
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