Deceased
Trevor Scott Besgrove
Demographics
46y, male
Date of death
2019-01-09/2019-03-17
Finding date
2020-11-02
Cause of death
cause of death cannot be determined
AI-generated summary
Trevor Besgrove, a 46-year-old man with complex mental health issues including borderline schizophrenia, depression, and a history of trauma and substance use, was found deceased in his Bicheno home after an estimated two-month absence. His body was in advanced decomposition, precluding autopsy determination of cause of death. He had disengaged from medical and psychological care in October 2017 despite documented mental health relapse. Clinical lessons include the importance of maintaining engagement with vulnerable patients with chronic mental illness, particularly those at risk of social isolation, and ensuring robust follow-up systems for patients who disengage from care. Earlier intervention when he became withdrawn after obtaining his driver's licence might have identified deterioration. Community-based mental health surveillance systems are critical for isolated individuals with complex psychiatric histories.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
59y · Male·Multiple injuries
Martin Carl Quiterio, a 59-year-old man with longstanding schizophrenia and suspected autism spectrum disorder, died on 3 January 2024 when he jumped from the 14th floor of a car park in West Perth. He had been discharge…
40y · Male·Unascertained
Nathan James Taylor, aged 40, died in Port Lincoln Prison on 24 March 2022 while in custody pending trial on witness interference charges. He had significant medical history including infective endocarditis with tricuspi…
36y · Male·Drowning
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 ps…
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —