Inquest into the death of Road Death 4 of 2024
Demographics
34y, male
Date of death
2024-02-03
Finding date
2024
Cause of death
Multiple blunt force injuries from motor vehicle crash (pedestrian struck)
AI-generated summary
A 34-year-old Indigenous male with schizophrenia and psychosis living in 24/7 supported care wandered from his care home on 3 February 2024 and was struck by a motor vehicle on Stuart Highway while walking in poor light conditions. He was wearing dark clothing without high-visibility gear despite a care plan requiring hi-vis clothing. His carer was occupied with cleaning tasks when he left unmonitored. The crash occurred during nautical twilight in an area with inoperative street lighting. Police analysis determined the collision was unavoidable at posted speed limits given the pedestrian's limited visibility. Clinical lessons include: the importance of actively implementing care plans (particularly hi-vis requirements for vulnerable patients at risk of wandering), the need for active supervision protocols during high-risk periods, and ensuring environmental factors (lighting maintenance) are addressed in duty-of-care settings.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- Wandering behaviour due to schizophrenia and psychosis
- Inadequate supervision during carer's cleaning activities
- Non-compliance with care plan requiring high-visibility clothing
- Poor lighting conditions at time of incident
- Inoperative street lighting at Jenkins Road intersection
- Pedestrian difficult to see in dark clothing on poorly lit roadway
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