Deceased
Linden Alan Kunoth
Demographics
24y, male
Date of death
2017-10-17
Finding date
2019-09-27
Cause of death
self-inflicted hanging
AI-generated summary
Linden Alan Kunoth, a 24-year-old Aboriginal man, died by suicide while on escorted leave from psychiatric care. He had been admitted with first-episode schizophrenia, presenting with florid psychosis and command hallucinations telling him to harm himself. Although sedated initially, he remained actively psychotic with intact delusions about being an Aboriginal god at discharge and throughout two admissions. He was granted escorted leave on 16-17 October 2017 while still psychotic, despite expert evidence indicating treatment-resistant illness with high suicide risk. Key failures included: absence of approved leave procedures (despite legislation requiring them for 17 years), inadequate risk assessment failing to recognise psychosis as a static risk factor, minimal discussion with parents about diagnosis/risks/supervision requirements, and no review before granting ongoing daily leave. The coroner found safety was not prioritised and leave was granted prematurely without appropriate risk mitigation.
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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