A 22-year-old man with treatment-resistant schizophrenia died by hanging while under guardianship with special powers of detention in supported independent living. He had attempted suicide by drinking bleach one month prior and was assessed at hospital but not detained. He experienced multiple stressors including COVID-19 isolation, social isolation, rejection by prior care workers, and concerns about legal consequences following a traffic accident involving his father. The coroner found the care provided by support workers was of high quality with appropriate medication and mental health monitoring. No procedural failures were identified. Clinicians should recognise warning signs of suicidal ideation in young people with treatment-resistant schizophrenia, particularly after suicide attempts, and consider the psychological impact of stressors such as isolation and legal concerns. Enhanced risk assessment and potentially higher levels of care consideration may be warranted in such cases.
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