Deceased
Lucas Richard Towndrow
Demographics
51y, male
Date of death
2016-12-13
Finding date
2018-05-17
Cause of death
Injuries sustained in a train incident
AI-generated summary
Lucas Towndrow, a 51-year-old involuntary psychiatric patient at Latrobe Regional Hospital, died by suicide on a railway track on 13 December 2016 after being granted unescorted leave to smoke. Shortly before leave was granted, he had been informed by his psychiatrist that his unescorted leave privileges were being revoked due to returning from previous leave appearing substance-affected. He terminated the consultation abruptly, then requested a cigarette break which a nurse authorized. The coroner found the risk assessment undertaken prior to granting leave was 'cursory and deficient', particularly given the preceding consultation. The hospital subsequently implemented revised leave and risk assessment protocols aligned with Chief Psychiatrist guidelines. The death highlighted the complexity of suicide risk assessment in mental health patients and the need for vigilant identification of warning signs such as anxiety and depressed mood.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
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