Deceased
Gary Dale Sargeant
Demographics
36y, male
Date of death
2020-09-09
Finding date
2026-05-28
Cause of death
Drowning
AI-generated summary
Gary Dale Sargeant, a 36-year-old Royal Australian Air Force member, died by drowning after absconding from Edinburgh Health Centre during an acute mental health crisis. Critical clinical failures included: a clinical psychologist's failure to read urgent referral documentation revealing longstanding suicidal ideation before assessment, preventing appropriate risk exploration; inconsistent and inadequately communicated risk assessments among clinical staff; failure to physically search the patient or remove his car keys despite acute suicide risk; and inadequate supervision—the patient was left unsupervised despite Mental Health Act powers being invoked and emergency transfer arranged. Preventable factors identified: reading referral documentation before first consultations; clear communication protocols regarding risk levels and supervision requirements; conducting searches for high-risk patients; maintaining continuous supervision; and improving clinical staff training on mental health legislation and procedures. The coroner found that either searching the patient and removing keys, or maintaining constant supervision, would have prevented the death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
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