Deceased
MS
Demographics
13y, male
Date of death
2020-02-16
Finding date
2025-02-05
Cause of death
asphyxia as a result of hanging
AI-generated summary
MS, a 13-year-old Year 8 student, died by suicide by hanging on 16 February 2020. In the weeks before his death, MS engaged in self-harm by cutting his arms and expressed suicidal ideation to close friends through online messaging, but these communications were not disclosed to his parents or school staff until shortly before his death. On 14 February 2020, a student informed a teacher, who emailed the school psychologist. The psychologist attempted to contact MS but he had already left school. She decided not to contact his parents that afternoon, instead scheduling him for Monday. Critical learning points: (1) A critical email from a parent warning of self-harm and suicide ideation was lost in a spam filter and never reached the principal; (2) The school psychologist's decision not to contact parents on Friday afternoon, despite concerning information, reflects significant workload pressures and incomplete risk assessment; (3) Informal student reports of peer concerns require robust follow-up processes. The coroner found the school's processes generally adequate but highlighted the need for improved protocols ensuring timely parental notification and effective handling of informal student reports regarding peer welfare.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
59y · Male·Shotgun wound to the head
A 59-year-old man with a work-related shoulder injury developed anxiety and depression, later expressing suicidal ideation during mental health treatment. His general practitioners and psychologist provided appropriate m…
47y · Female·insulin and mixed drug toxicity, the result of actions undertaken by the decease…
A 47-year-old woman with depression and a history of suicidal ideation died from insulin and mixed drug toxicity after deliberately injecting insulin from her daughter's insulin pens. She had been seen by her GP seven ti…
Male·Hunt: self-inflicted gunshot wound to head; Reynolds: self-inflicted gunshot wou…
This coronial finding examined four police suicides in Tasmania between 2016-2020. Constable Hunt died by gunshot wound after being stood down from duty without welfare support; his personal phone was unlawfully seized, …
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. Some material may have been redacted or restricted by court order or privacy requirements. 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 — report an inaccuracy here.