Deceased
Grant Elliot Phillips
Demographics
29y, male
Date of death
2007-05-07
Finding date
2012-10-12
Cause of death
Multiple injuries sustained in a train incident (intentional self-harm)
AI-generated summary
Grant Phillips, 29-year-old with schizophrenia and complex psychiatric history including multiple suicide attempts, was admitted involuntarily to Broadmeadows Inpatient Psychiatric Unit on 5 May 2007. Despite being assessed as suitable for the Low Dependency Unit (LDU) with 15-minute observations, he absconded over a 1.4-metre fence on the evening of 7 May 2007 and died by suicide at a railway crossing. Key clinical issues: lack of psychiatrist continuity of care between community and inpatient services influenced placement decision; admission to LDU rather than High Dependency Unit (HDU) may have been inappropriate given recent CTO revocation for non-compliance and significant suicide risk; however, even HDU admission with a weekend stay may not have altered outcome as risk was reassessed as manageable by the consultant psychiatrist on the Monday morning. The coroner found no preventable death but highlighted importance of continuity of psychiatric care across service levels.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
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