Deceased
Renee Andrea Treen
Demographics
24y, female
Date of death
2010-06-01
Finding date
2014-01-29
Cause of death
multiple injuries from jumping off Bulla Road overpass onto Tullamarine Freeway
AI-generated summary
Renee Treen, aged 24, died by suicide from the Bulla Road overpass while an involuntary psychiatric patient. Critical failures included: inadequate assessment of suicide risk (prior freeway-adjacent behaviour not weighted), delayed notification to police (1.35 hours after absconding), insufficient observation frequency following second absconding episode, and lack of structured monitoring for approved leave conditions. The unit operated under "least restrictive" principles but failed to implement safeguards when clinically indicated. Nicotine withdrawal management was not addressed despite recognised impact on mental state. Clinical lessons: suicide risk assessments must incorporate behaviour proximate to admission; second absconding episodes warrant escalated containment; observation frequencies must increase with risk changes; leave conditions must be clearly documented and monitored; and nicotine dependence requires active management in psychiatric units.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
36y · Male·Drowning
Gary Dale Sargeant, a 36-year-old Royal Australian Air Force member, died by drowning after absconding from Edinburgh Health Centre during an acute mental health crisis. Critical clinical failures included: a clinical ps…
40y · Male·Unascertained
Nathan James Taylor, aged 40, died in Port Lincoln Prison on 24 March 2022 while in custody pending trial on witness interference charges. He had significant medical history including infective endocarditis with tricuspi…
44y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest in the setting of p…
Elizabeth Ferris, a 44-year-old woman with schizoaffective disorder and polysubstance use disorder, died from hypoxic ischaemic encephalopathy following cardiac arrest in the setting of presumed drug toxicity. She was fo…
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. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. 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 —