Coroner's Finding: AZ 2022 TASCD 60
Deceased
AZ
Demographics
16y, male
Date of death
2017-03-07
Finding date
2022-01-28
Cause of death
Multiple blunt traumatic injuries from fall from height
AI-generated summary
A 16-year-old boy with depression and suicidal ideation was discharged from an inpatient adolescent mental health facility in Victoria after 20 days. Two days later, he died by suicide at a cliff location he had previously mentioned. While his treatment and diagnosis were generally appropriate, the coroner found that the discharge planning was inadequate. Specifically, the treating psychiatrist did not adequately communicate to the patient's mother the specific risk factors—particularly that he had expressed intent to jump from cliffs upon returning home—and failed to discuss practical safety measures with the parents post-discharge. The coroner noted that more explicit information about the timing, method, and specific nature of suicide risk, combined with a concrete safety plan, should have been provided. Additionally, the unavailability of appropriate adolescent inpatient mental health services in Tasmania meant the patient required interstate treatment, separating him from family supports.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- Suicide by jumping from cliffs
- Inadequate discharge planning and risk communication
- Insufficient discussion of specific suicide risk with parents
- Lack of concrete safety plan post-discharge
- High-risk period immediately following discharge
- Lack of immediate post-discharge follow-up support
- Geographic separation from family supports due to interstate treatment
- Intoxication on day of death
- Lack of dedicated adolescent inpatient mental health services in Tasmania
Coroner's recommendations
- Adopt and reiterate the 2015 recommendations of Coroner McTaggart regarding establishment of a dedicated inpatient unit for adolescents aged 12-25 years with acute mental illness or suicidality
- Establish a multi-disciplinary facility for young persons suffering from acute mental illness or suicidality with comprehensive through-care and after-care model
- Establish state-wide positions of suicide prevention co-ordinators to provide outreach between hospital discharge and community services
- Ensure appropriate community-based services are available to Tasmanian residents immediately after discharge from interstate inpatient facilities
- Inform interstate inpatient facilities of available community-based services in Tasmania to ensure continuity of care
- Require that inpatient facilities discharging patients interstate ascertain what follow-up services are available and refer patients to those services, particularly in the days immediately after discharge
Full text
Related cases
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 —