Frederick Russell Morgan, a 48-year-old stockbroker, disappeared on 15 July 1971 from Mt Martha beach. He had experienced severe depression triggered by business financial crises, tax assessment concerns, and his father's death. Despite seeing his psychotherapist Dr R. on 15 July 1971—when Mr Morgan disclosed suicidal preoccupation for ten days—he was not admitted to hospital or given immediate intensive psychiatric care. Dr R. believed the danger had passed after their consultation, but Mr Morgan's condition deteriorated that same day. He left home and was never found. The coroner found he likely died by suicide. Clinically, this case highlights the risks of outpatient management of acute suicidal ideation without hospitalisation, the importance of recognising warning signs in high-stress individuals, and the potential inadequacy of medication adjustment alone in acutely suicidal patients.
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