Deceased
Justin Damien Connell
Demographics
37y, male
Date of death
2013-02-13
Finding date
2015-12-02
Cause of death
Multiple injuries (motor vehicle impact – pedestrian)
AI-generated summary
Justin Connell, a 37-year-old man with schizophrenia, died from multiple injuries sustained in a pedestrian–motor vehicle collision on 13 February 2013. He had been diagnosed with schizophrenia in October 2012 and prescribed antipsychotics, but unilaterally reduced his medication dosage without psychiatrist knowledge. He became increasingly delusional, and by early February believed police were coming to arrest him for a crime committed 32 years earlier. After self-inflicting neck wounds, he presented to hospital at 2:22am but was discharged from the ED around 6:45am without involuntary psychiatric assessment. He was then hit by a truck while stepping into traffic. Key clinical lessons: fragmented information sharing between police, paramedics, and ED staff resulted in loss of critical collateral history about his delusional state; Dr L.'s assessment lacked input from his partner or psychiatric history; his psychiatrist (Dr W.) made no follow-up contact after he missed an appointment on 22 January. The coroner found that better information flow and collateral history from his partner could have changed outcome.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
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