Coroner's Finding: Johns, Ross Alexander
Deceased
Ross Alexander Johns
Demographics
36y, male
Date of death
2021-06-14
Finding date
2023-05-08
Cause of death
hanging, with contributing factors of alcohol dependence and depression
AI-generated summary
Ross Johns, aged 36, died by hanging on 14-15 June 2021 after a long history of bipolar disorder, major depression, and alcohol dependence. He was discharged from Northside Mental Health Unit on 9 June 2021 following admission for overdose and suicide attempt. The coroner found no deficits in his treatment or care, and that procedures and protocols were correctly followed. His family raised concerns about premature discharge, inadequate ED treatment of his May suicide attempt, and phone-only follow-up by the Crisis Assessment and Treatment Team. However, the coroner accepted expert evidence that extended hospitalization would not have prevented his death, given his severe, long-standing mental illness, alcohol dependence, and impulsive risk profile. The coroner found his care appropriate and made no recommendations.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Drugs involved
Contributing factors
- long-standing bipolar disorder and major depression
- alcohol dependence and active alcohol use
- recent relationship breakdown and separation from wife
- recent suicide attempt by overdose (31 May 2021)
- impulsive suicide risk particularly when intoxicated
- previous psychiatrist ended patient relationship by email
- brief and inadequate ED treatment of May 2021 suicide attempt
- discharge from Northside Mental Health Unit on 9 June 2021
- failure to engage with recommended residential rehabilitation
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