Coroner's Finding: Mr S
Deceased
Mr S
Demographics
58y, male
Finding date
2016-11-21
Cause of death
asphyxia
AI-generated summary
A 58-year-old man with depression and suicidal ideation was assessed by his general practitioner, then taken to hospital by his partner. In the emergency department he was triaged with sufficient safety concerns to warrant admission. A psychiatrist assessed him as moderate suicide risk but could not admit him due to insufficient mental health ward beds. Instead, he was allowed to return home briefly to shower and change clothes, with instructions to return by 4pm. While his partner showered, he walked to nearby bushland and died by asphyxia. The coroner found that with adequate mental health bed capacity, he would likely have been admitted and would not have died. The coroner expressed concern about the shortage of mental health beds at Royal Hobart Hospital.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- depression
- insufficient mental health ward beds
- discharge without admission despite moderate suicide risk
- suicidal ideation
Coroner's recommendations
- Mental health bed capacity at Royal Hobart Hospital should be increased to adequately accommodate patients identified at moderate suicide risk
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