Coroner's Finding: de-identified IB
Demographics
21y, male
Date of death
2019-06-01
Finding date
2025-06-30
Cause of death
drowning
AI-generated summary
A 21-year-old male with schizophrenia and cannabis use died by suicide after jumping from the Tasman Bridge. He had been admitted to Royal Hobart Hospital on 7 May 2019 with suicidal ideation and auditory hallucinations commanding him to kill himself. Following stabilisation on increased antipsychotic medication, he was transferred to Mistral Place, a community-based step-down psychiatric facility, on 29 May 2019 under a Treatment Order. Staff documented improvement, denied suicidal ideation on 27 May, and he appeared well on 1 June. He left the facility without stated intent and jumped from the bridge spontaneously. The coroner found his hospital care and transfer to Mistral Place clinically appropriate given his clinical improvement and alignment with least-restrictive principles. However, the absence of effective bridge barriers may have prevented a spontaneous act by allowing time for reconsideration or help-seeking, as he had done previously.
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Specialties
Drugs involved
Clinical conditions
Contributing factors
- schizophrenia with active symptoms (paranoia, auditory hallucinations)
- suicidal ideation at time of presentation to hospital
- cannabis use with negative impact on medication efficacy
- low barrier height on Tasman Bridge allowing easy access
- spontaneous, unplanned nature of jump with no advance warning
- open access to bridge pathways at all times
Coroner's recommendations
- The government should urgently implement structural modifications to the Tasman Bridge with a key aim of eliminating suicides at the bridge
Full text
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