Finding into death of Pratik Dugar
Deceased
Pratik Dugar
Demographics
27y, male
Date of death
2012-10-08
Finding date
2014-02-03
Cause of death
Multiple injuries sustained when struck by a train
AI-generated summary
A 27-year-old man with a history of anxiety disorder and depression died by suicide, placing himself in front of a train. He had presented to emergency with suicidal ideation and overdose one week prior and was assessed as low suicide risk following crisis assessment team review. He had ceased sertraline unilaterally two months before death and was using cannabis to self-medicate anxiety. Clinical lessons include the importance of risk reassessment in patients with mood disorders who discontinue antidepressants, ensuring adequate follow-up after emergency presentations for suicidal ideation, and considering the potential increased risk when patients self-discharge from psychiatric care or default appointments. The coroner found no clinical failings but recommended improved railway crossing safety features.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Contributing factors
- History of anxiety disorder with depression
- Unilateral cessation of sertraline antidepressant medication
- Self-medication with cannabis
- Recent psychosocial stressors including death of brother and friend
- Suicidal ideation presentation one week prior to death
- Assessment as low suicide risk despite recent overdose attempt
Coroner's recommendations
- Consideration be given to making the pedestrian railway crossing at Flora Road, Clayton active through the provision of pedestrian gates and audible tones
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