Deceased
Mr D
Demographics
57y, male
Date of death
2014-07
Finding date
2016-01-29
Cause of death
Multiple fatal injuries following a fall from height onto rocks
AI-generated summary
A 57-year-old European-born man died by suicide after falling from a cliff in northern Tasmania in July 2014. He had experienced progressive mental health deterioration over 12 months, including depression, anxiety, and suicidal ideation, triggered by family stressors (son's drink-driving charges), work concerns, and physical health worries. He had a significant family history of mental illness and suicide. After a previous suicide attempt by asphyxiation, he was admitted to a psychiatric inpatient unit for assessment and treated with antidepressants and anxiolytics. He was discharged after 5 days when suicidal ideation cleared, followed by Crisis Assessment Team support. However, the coroner identified that follow-up care was prematurely ceased based solely on the patient's positive self-reports, which did not reflect his actual mental state as observed by his wife, who noted he continued expressing feelings of being a burden. The coroner recommended verifying patient self-reports with family members or carers to avoid premature closure of mental health cases.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
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