Deceased
Rajesh Pala
Demographics
34y, male
Coroner
Coroner Audrey Jamieson
Date of death
2009-04-24
Finding date
2012-04-12
Cause of death
Mixed drug toxicity
AI-generated summary
Rajesh Pala, a 34-year-old man with polysubstance abuse disorder, borderline personality disorder, and chronic depression, died from mixed drug toxicity following discharge from The Alfred psychiatric unit. He was admitted to hospital on 20 April 2009 with suicidal ideation and commenced on methadone. On 23 April, he expressed to his case worker that he would overdose if discharged. Despite these threats, he was discharged to crisis accommodation at Hanover House with no psychiatric follow-up arranged. He died by overdose on 24 April 2009. The coroner found the discharge was appropriately managed based on risk assessment at the time, as Rajesh's suicidal threats were contextual to situational crises. However, the coroner identified inadequate communication between hospital staff and the case worker about Rajesh's concerns, which disadvantaged the case worker's ability to effectively engage with him. The death was not foreseeable and likely not preventable.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
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