Deceased
Damian Luke Summers
Demographics
42y, male
Date of death
2019-11-29
Finding date
2021-12-03
Cause of death
hanging, an action taken by himself with the intention of ending his life
AI-generated summary
A 42-year-old man with acute psychosis was hospitalised for 26 days and discharged from a psychiatric facility to an isolated rural island where his partner and children had left. He had poor insight into his mental illness, denied suicidal ideation throughout admission, and had low suicide risk scores. He died by suicide within 24 hours of discharge. The treating psychiatrists and Root Cause Analysis panel concluded his death could not have been predicted. However, the coroner identified several missed opportunities: no telephone contact from treating team to his general practitioner on discharge day; discharge summary sent by email after clinic closure so GP was unaware of his return; no copy of the Treatment Order provided to GP; discharge on a Friday when weekend services were unavailable; and insufficient early engagement with his only realistic support person (sister) regarding his condition and medication requirements. The case highlights communication failures between psychiatric facilities and rural general practitioners, and the challenges of discharging patients with limited community support.
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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