Inquest into the death of Dean Jigili
Deceased
Dean Jigili
Demographics
23y, male
Date of death
2015-01-14
Finding date
2016-07-11
Cause of death
self-inflicted hanging
AI-generated summary
Dean Jigili, a 23-year-old Aboriginal man, died by hanging after absconding from Cowdy Ward mental health unit on 13 January 2015. He had first-episode psychosis likely triggered by cannabis use, complicated by apparent genetic predisposition to schizophrenia. Despite multiple admissions and medication management, he remained symptomatic with ongoing command hallucinations. He was transferred from the secure Joan Ridley Unit to the less-secure Cowdy Ward on the same day he absconded. The coroner found the transfer decision reasonable without hindsight, noting his improved mental state and previous tolerance of Cowdy Ward. Key issues included delayed discharge summaries, inadequate inter-team communication between units, and security vulnerabilities (unlocked doors, scalable fence). The mental health service implemented substantial improvements post-incident including security upgrades, new communication protocols, and CCTV installation. No clinical error was identified, but systems improvements were warranted.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- first-episode psychosis secondary to cannabis use
- likely underlying schizophrenia with genetic predisposition
- ongoing command hallucinations despite medication
- poor medication adherence between admissions
- transfer from secure to less-secure ward on day of absconding
- inadequate communication between JRU and Cowdy Ward teams
- lack of discharge summary at time of transfer
- security vulnerabilities: unlocked door and scalable fence
- little insight into illness at time of transfer
- rated significant risk of absconding but only 15-minute observations
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