Ross Campbell, a 40-year-old man with a history of family violence perpetration, alcohol abuse, and undiagnosed mental illness, died by hanging. He had attended a Men's Behavioural Change Program in 2011 following a family violence incident, but declined follow-up mental health services. His GP identified possible depression, anxiety and bipolar disorder, but he did not engage with recommended psychiatric care. Clinicians identified suicidal ideation during his MBCP intake assessment but conducted no formal suicide risk assessment. His violent behaviour and alcohol consumption escalated after his relationship breakdown with his wife in December 2013. Clinical lessons include: formal suicide risk assessment is essential for family violence perpetrators with disclosed suicidal ideation; follow-up monitoring after behavioural programs is critical; and engagement strategies for reluctant male patients with mental health needs require improvement. Better coordination between domestic violence services and mental health providers could identify and address cumulative suicide risk.
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Specialties
general practicepsychiatrypsychology
Error types
communicationsystem
Drugs involved
alcohol
Clinical conditions
depressionanxietypossible bipolar disorderalcohol use disorderfamily violence perpetrationsuicidal ideation
Contributing factors
alcohol abuse and dependence
family violence perpetration and relationship breakdown
undiagnosed or inadequately managed mental illness (depression, anxiety, possible bipolar disorder)
suicidal ideation disclosed but not formally assessed
poor engagement with mental health services
lack of follow-up monitoring after Men's Behavioural Change Program completion
escalating anger and abusive behaviour in weeks prior to death
Coroner's recommendations
That No to Violence provide an updated minimum standards for Men's Behavioural Change Programs to incorporate a requirement for suicide risk assessment upon eligibility and throughout Men's Behavioural Change Programs
That the Victorian Government establish a state wide accreditation process for Men's Behavioural Change Programs in order to ensure that all programs meet an updated minimum standards as published by No to Violence
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