Matthew Liddell, a 28-year-old former Navy serviceman with severe post-traumatic stress disorder and depression following the 1998 HMAS Westralia fire, died by hanging in a psychiatric hospital. He had been admitted on 8 November 2003 after separation from his de facto wife triggered acute deterioration. He was discharged on weekend leave on 21 November and returned early on 22 November distressed about police investigation into domestic violence proceedings. Nursing staff appropriately assessed him, noted his anger had settled, and observed him socialising that evening appearing calm and cheerful. He took sleeping medication at 12:40am and was found hanging at 1:05am. The coroner found no evidence that his psychiatrist should have been called, that more frequent observations were warranted based on his presentation, or that the hospital's safety procedures were inadequate. The case highlights the difficulty of predicting suicide in open psychiatric units and the importance of family-hospital communication.
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open psychiatric unit without locked doors or secure environment
availability of ligature points (shower taps) in bathroom
Coroner's recommendations
Improvement of communication between family carers and hospital carers regarding patient concerns and observations during leave
Implementation of formal documentation requiring family carers to sign patients back in and advise of any concerns about the leave experience
Continued open and continuing communication between family, friends, doctors and nurses of persons suffering depression and at risk of suicide
Recognition that while hospitals can improve physical safety, it is impossible to eliminate all items and change the physical environment to remove all risk of suicide
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