Coronial
SAhospital

Coroner's Finding: DITTMAR Damien Paul

Deceased

Damien Paul Dittmar

Demographics

35y, male

Date of death

2006-05-16

Finding date

2008-10-24

Cause of death

neck compression due to hanging

AI-generated summary

A 35-year-old man with chronic depression, alcohol dependence and amphetamine abuse was detained at the Queen Elizabeth Hospital Emergency Department on 15 May 2006 after presenting intoxicated with suicidal ideation. He was held in Consult Room C pending psychiatric assessment, but absconded between 7:00-7:15pm during a nursing shift handover while a security escort was being arranged. He died by suicide the following morning. Clinical lessons: (1) detained patients require continuous observation—nursing staff alone cannot safely supervise patients determined to leave; (2) security escort arrangements must be expedited after detention; (3) police response to absconded detained patients requires urgent protocols and follow-up visits, not reliance on family assurances; (4) documented high suicide risk with stated suicidal ideation warranted more intensive initial management.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

psychiatryemergency medicine

Error types

communicationsystemdelayprocedural

Drugs involved

alcoholamphetamineantidepressants

Clinical conditions

depressionalcohol dependenceamphetamine abusesuicidal ideationpersonality disorder

Contributing factors

  • absconding from psychiatric detention while acutely suicidal
  • delayed security escort arrangement following detention
  • nursing shift handover creating supervision gap
  • inadequate police search and follow-up at identified address
  • reliance on grandmother to report return despite her advanced age and apparent confusion
  • chronic alcohol and amphetamine abuse
  • depression exacerbated by recent relationship loss
  • personality disorder with impulsive tendencies and limited coping abilities

Coroner's recommendations

  1. Clinical staff of Queen Elizabeth Hospital Emergency Department and security contractors must develop protocols ensuring that patients detained under Mental Health Act 1993 are not left unobserved following detention while in Emergency Department
  2. Clinical staff and security contractors must develop strategies to more efficiently and effectively instigate searches for persons detained under Mental Health Act 1993 who have absconded or are missing
  3. If Section 254 of Criminal Law Consolidation Act does not apply to absconding from Mental Health Act detention, Attorney-General and Minister for Mental Health should consider introducing legislation to render it an offence to knowingly assist an absconded detainee to avoid apprehension
  4. Commissioner of Police must ensure that detained persons under Mental Health Act 1993 who leave detention without permission are regarded as persons unlawfully at large liable to apprehension, not merely missing persons, and that vigour is brought to bear to facilitate their return to place of detention
Full text
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Source and disclaimer

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