Deceased
Luke John De Piazza
Demographics
34y, male
Date of death
2017-03-03
Finding date
2018-06-26
Cause of death
hanging
AI-generated summary
Luke De Piazza, a 34-year-old man with long-standing mental health issues, died by hanging on 3 March 2017. Six days prior, he had voluntarily discharged from a psychiatric inpatient unit. On the day of death, he presented to the ED reporting suicidal ideation, then attended a psychiatric unit where he became agitated and was apprehended by police under section 22 of the NSW Mental Health Act. Critically, police were instructed by the attending doctor to leave before formal mental health assessment was completed. De Piazza subsequently absconded from the hospital and died by hanging hours later. The coroner found no fault with the doctor's clinical judgment or the police's departure, but identified a significant systemic issue: unclear responsibility for security and custody transfer between NSW police and hospital staff at the NSW/Victoria border. The coroner highlighted the need for formalized handover protocols clearly documenting when hospital staff accept sole responsibility for the patient's care and security.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
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