Ryan, Adam Trent
Deceased
Adam Trent Ryan
Demographics
30y, male
Date of death
2009-07-12
Finding date
2013-01-18
Cause of death
asphyxia due to hanging (suicide)
AI-generated summary
30-year-old Adam Trent Ryan died by suicide via hanging in July 2009. Multiple systemic failures preceded his death. The Community Mental Health Service failed to communicate Mr Ryan's past suicide attempt to the hospital and did not inform treating psychiatrist Dr K. of hospital admission. Nurse Gordon failed to document a recent suicide attempt reported by police. Dr G. prescribed unrestricted diazepam (50 tablets) despite Mr Ryan's substance abuse history, and conducted only a 10-15 minute discharge assessment without reviewing the file. When Mr Ryan re-presented acutely intoxicated hours after discharge, nursing staff failed to appropriately escalate concerns, provided him unrestricted medication on discharge, and failed to locate him when he went missing from hospital. Staff later improperly rewrote and destroyed medical notes post-incident. While causation to death cannot be proven, systemic failures in communication, documentation, risk assessment, and medication management created dangerous gaps in care.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Drugs involved
Contributing factors
- failure of Community Mental Health Service to communicate past suicide attempt to hospital
- failure of psychiatrist to advise hospital of past suicide attempt in referral letter
- failure of nurse to document recent suicide attempt reported by police
- failure of discharge physician to restrict diazepam prescription despite substance abuse history
- inadequate discharge assessment and counselling
- failure to escalate when patient re-presented acutely intoxicated hours after discharge
- failure to appropriately locate missing patient
- provision of unrestricted medication on re-discharge
- lack of inter-service communication between hospital, CMH, and ATODS
- subsequent improper destruction and rewriting of medical notes
Coroner's recommendations
- Community Mental Health Service in every District provide full copies of records and files to treating hospital whenever a CMH patient is admitted to hospital
- Requirement that Community Mental Health Service advise any treating specialist consultants of admission of a CMH patient as in-patient of any hospital
- Nursing staff be specifically instructed to record any reference to any active suicidal behaviour by or depression of a patient from any credible source, particularly police officers
- Handover of patients by one medical officer to another be recorded in writing, including specific written record of daily medication dose limitations for such patients
- Protocol established to ensure family member of person admitted to hospital who then absconds is contacted by hospital immediately and if necessary hospital enlists assistance of police service
- Protocol established that nursing staff not return prescription medication to patients in circumstances where patient's circumstances have changed since previous prescription by medical officer and where patient is unwilling to be reviewed by medical officer
- Upon death of patient recently treated at hospital in Queensland, patient's hospital records be immediately sealed and secured to prevent tampering or interference before records provided to Coroner
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —