Finding into death of Miroslaw Dziczkowski
Deceased
MIROSLAW DZICZKOWSKI
Demographics
40y, male
Date of death
2013-05-09
Finding date
2016-12-05
Cause of death
UNDETERMINED - natural causes (most probably natural disease; starvation could not be proven or refuted at autopsy)
AI-generated summary
Miroslaw Dziczkowski, a 40-year-old man with paranoid schizophrenia managed under a Community Treatment Order, disappeared in January 2013 after withdrawing $7300 and relocating to a caravan park without notifying his mental health team or family. He left notes indicating intent to end his life by starvation and was found deceased in May 2013, having lost 29kg. The cause of death remained undetermined at autopsy despite natural causes being confirmed. While Monash Health's mental health management was comprehensive and appropriate, the coroner identified inadequacies in the police missing person investigation. Risk factors suggesting high-risk categorisation were not appropriately identified or reassessed during the initial month of investigation. The police response, though generally compliant with policy, lacked urgency given his involuntary psychiatric status and known history of self-neglect when unmedicated. Improved risk assessment tools and regular reassessment protocols are recommended.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Contributing factors
- Paranoid schizophrenia with history of self-neglect when unmedicated
- Non-compliance with antipsychotic medication after absconding
- Planned disappearance with intent to isolate from treatment and family
- Stated intention to commit suicide by starvation
- Significant weight loss from 82.1kg to 53kg over approximately 3.5 months
- Inadequate risk assessment in missing person investigation
- Failure to identify and escalate mental health risk factors in police response
- Lack of regular risk reassessment during 30-day initial investigation period
Coroner's recommendations
- Chief Commissioner of Police should revise Form L18A, particularly the Risk Factor Guide in Part 2, to: (a) include the missing person's status under mental health legislation as a risk indicator; and (b) provide clear guidance for nominal and supervising members assessing identified risks, resolving apparent inconsistency between mandatory instructions for risk indicators 1-8 and general instruction that weighting depends on circumstances of each case
- Chief Commissioner of Police should introduce a formal process and policy requiring supervising officers to review risk assessments at specified intervals to account for the likelihood that a missing person's risk of harm is not static over time, and which monitors compliance with this process
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