Carl Ranthe, a 26-year-old with schizophrenia, presented to Frankston ED on 1 January 2009 after a fight and alcohol consumption. Social worker Manfred Rapp conducted a 15-minute assessment, found Carl not psychotic, low suicide risk, and arranged return to the Community Care Unit via taxi. Carl left the ED without taking the taxi and later jumped from West Gate Bridge. The coroner found both Rapp and nurse Gordon McRae provided professional, appropriate care with reasonable clinical judgement. The clinicians had no reasonable basis to forecast Carl's decision to end his life. Care was of high standard; the death reflects the tragic unpredictability of suicide risk in complex mental illness rather than clinical failure.
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