Deceased
Andrew David Hollonds
Demographics
37y, male
Date of death
2009-11-19
Finding date
2013-04-24
Cause of death
compression of the neck consistent with hanging
AI-generated summary
Andrew David Hollonds, a 37-year-old man with personality disorder, substance misuse, and recent psychosis, presented to hospital after a suicide attempt (temazepam overdose) following job loss. He explicitly threatened hanging to his father. Although detained under the Mental Health Act with documented suicide risk, he was permitted unaccompanied cigarette breaks and subsequently absconded from the Emergency Department. Police located him hanging in his backyard within an hour. Key clinical failures included: inadequate supervision of a detained high-risk patient, permitting unsupervised departures despite explicit suicide threat, and ambiguous protocols regarding Code Black escalation and missing patient procedures. The coroner identified policy gaps around managing detained smokers and recommended clearer guidance on supervision requirements and consideration of alternatives such as nicotine replacement or secure outdoor areas.
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
Male·suicide
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