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Coroner's Finding: Green, Paul William

Deceased

Paul William Green

Demographics

66y, male

Date of death

2017-05-09

Finding date

2018-08-31

Cause of death

carbon monoxide poisoning due to inhalation of exhaust gases from a lawn mower

AI-generated summary

Paul William Green, a 66-year-old retired engineer with longstanding depression, anxiety, PTSD, and chronic alcohol abuse, died by intentional carbon monoxide poisoning from a lawn mower exhaust. He had a prior suicide attempt in 2016 and was taken into protective custody in April 2017 after expressing fear of incarceration related to breach-of-order charges. He was discharged with community mental health follow-up but received inadequate ongoing support. Key clinical lessons include: (1) older males with multiple psychiatric comorbidities, physical health issues, social isolation, and substance abuse require intensive, coordinated mental health intervention; (2) information sharing between police, mental health services, and primary care improves suicide risk assessment; (3) follow-up after protective custody admissions must be robust, not minimal; (4) fear of incarceration in vulnerable individuals warrants immediate escalation of mental health support.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Contributing factors

  • severe depression with suicidal ideation
  • anxiety and panic attacks
  • post-traumatic stress disorder
  • chronic alcohol abuse
  • marital separation in November 2016
  • fear of incarceration following breach of family violence order
  • social isolation and weak support network
  • inadequate mental health treatment in the two years before death
  • chronic lung injury from 1973 motor vehicle crash
  • obsessional personality traits

Coroner's recommendations

  1. Improved centralisation of mental health and police records to enable better-informed suicide risk assessment by professionals
  2. Utilisation of the Tasmanian Suicide Register (established 2017) to develop targeted prevention strategies for suicide in older persons
  3. Greater intensity of mental health follow-up and support after protective custody admissions for suicide risk
  4. Enhanced coordination between mental health services, police, and primary care in suicide prevention
Full text

Source and disclaimer

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