Coronial
TAScommunity

Coroner's Finding: de-identified HN

Demographics

42y, male

Date of death

2022-05-04

Finding date

2025-06-30

Cause of death

Drowning following chest injuries sustained from jumping from the Tasman Bridge

AI-generated summary

A 42-year-old man with long-standing, well-managed paranoid schizophrenia died by suicide from the Tasman Bridge. He had been compliant with clozapine therapy for over 20 years, maintained psychiatric stability, and had no prior suicide attempts or documented suicidal ideation. His death was not foreseeable based on available clinical information. The coroner noted his fear of being left alone after his mother and grandmother's deaths may have precipitated the act, but this was never discussed with family or clinicians. The coroner emphasised structural vulnerabilities of the bridge itself as a suicide prevention issue requiring urgent government action.

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

Specialties

psychiatrygeneral practice

Drugs involved

clozapine

Clinical conditions

paranoid schizophreniatreatment-resistant schizophreniadrowningtension pneumothoraxrib fracturespulmonary oedema

Contributing factors

  • Long-standing paranoid schizophrenia
  • Fear of being left alone after death of mother and grandmother
  • Low safety barriers on Tasman Bridge
  • Easy public access to bridge pathways

Coroner's recommendations

  1. The government urgently implement structural modifications to the Tasman Bridge with a key aim of eliminating suicides at the Tasman Bridge
Full text

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