Coroner's Finding: THOMSON Wayne Mark
Deceased
Wayne Mark Thomson
Demographics
47y, male
Date of death
2000-02-14
Finding date
2002-01-03
Cause of death
neck compression due to hanging
AI-generated summary
Wayne Mark Thomson, aged 47, died by hanging on 14 February 2000. He made multiple attempts to seek help for suicidal ideation in the preceding three days, including visiting his GP, calling a crisis assessment service (EACIS), attending the Royal Adelaide Hospital ED, and receiving a home visit from EACIS workers. Each assessment failed to identify risk adequately. His GP provided a 6-month antidepressant prescription without proper assessment at their first consultation. The ED doctor dismissed a triage note of suicidality without psychiatric consultation, documenting insufficient mental state examination details. EACIS workers failed to fully explore documented warning signs including a noose found in his unit, delusional ideation, substance abuse, hepatitis C fears, and poor social supports. The coroner concluded assessment and management were inadequate and that he required specialist psychiatric input that was not provided.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- inadequate assessment by general practitioner
- inadequate mental state examination by ED doctor
- failure to escalate to psychiatric specialist
- inadequate documentation of psychiatric assessment
- inadequate home assessment by EACIS despite warning signs
- presence of police interfering with therapeutic assessment
- multiple referrals without clear diagnostic understanding
- failure to contact hospital regarding concurrent ED attendance
- insufficient exploration of suicidal ideation that fluctuated between contacts
- failure to recognize possible psychotic features
Coroner's recommendations
- Support continuation of ACIS (now EACIS) review of practices and procedures to improve worker performance and ensure early access to qualified psychiatric treatment
- Develop or modify protocol between SAPOL and EACIS to provide guidance when attending premises jointly, ensuring psychiatric patients can be assured police presence is for security/support rather than law enforcement, to avoid undermining therapeutic assessment
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