Deceased
Caleb Sody
Demographics
20y, male
Date of death
1998-07-25
Finding date
2000-04-28
Cause of death
ruptured heart and aorta due to fall from a height
AI-generated summary
A 20-year-old male with newly diagnosed disorganised schizophrenia died by suicide from a fall from the 5th floor of a hospital maternity building while detained under the Mental Health Act. He had been admitted to the Cramond Clinic (an open psychiatric ward) on 9 July 1998 and was classified for 30-minute observation intervals. Although he showed improvement by 24 July, he left the ward undetected around 6.50pm on 25 July. Critical delays occurred: staff did not report him missing to hospital security until approximately 3.5 hours after his disappearance was noted, and the procedure for missing patients lacked clear timelines. The coroner found that an alarm should have been raised to security within 30 minutes of his unaccounted absence, and that the missing persons procedure required urgent amendment to specify escalation timeframes and security notification protocols.
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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