Coronial
VICcommunity

Finding into death of Tomislav Brekalo

Deceased

Tomislav Brekalo

Demographics

29y, male

Date of death

2012-03-17

Finding date

2015-04-09

Cause of death

Injuries sustained in a fall from a height

AI-generated summary

A 29-year-old man with chronic paranoid schizophrenia died from injuries sustained after jumping from the EJ Whitten Bridge. He had a 5-year history of psychiatric illness with recurrent psychotic episodes despite treatment with antipsychotic medications including olanzapine. In the months before death, his mental health deteriorated significantly; he lost employment and repeatedly refused medication reviews. His psychiatrist had trialled multiple antipsychotics but found olanzapine most effective, though the patient complained of sedation. Just prior to death, medication was being switched again. This case highlights how inadequately managed chronic schizophrenia with poor insight, repeated medication non-compliance, and loss of employment support can contribute to suicide risk. The coroner identified the EJ Whitten Bridge as a suicide hotspot and made recommendations for safety barriers, noting that evidence-based suicide prevention requires physical barriers to prevent access.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Contributing factors

  • chronic paranoid schizophrenia with poor insight
  • repeated non-compliance with prescribed medication
  • recurrent psychotic episodes despite treatment
  • deteriorating mental health in mid-2011
  • repeated unsuccessful medication trials due to reported side effects
  • loss of employment in February 2012
  • failure to attend medical review despite family encouragement
  • medication changes in final days before death
  • identification of location as suicide hotspot with elevated activity

Coroner's recommendations

  1. VicRoads urgently liaise with incoming Victorian State Government and Federal Government to secure funding for immediate installation of temporary public safety barriers on the EJ Whitten Bridge to prevent jumping suicides
  2. VicRoads urgently liaise with incoming Victorian State Government and Federal Government to secure funding for permanent public safety barriers on the EJ Whitten Bridge to prevent jumping suicides
Full text

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