Finding into death of Damon Brenden Amiet
Deceased
Damon Brenden Amiet
Demographics
25y, male
Coroner
Deputy State Coroner Paresa Spanos
Date of death
2013-04-13
Finding date
2020-01-31
Cause of death
Injuries sustained when struck by a train (suicide)
AI-generated summary
Damon Brenden Amiet, a 25-year-old with schizoaffective disorder, borderline personality disorder, and antisocial personality traits, was admitted to a psychiatric inpatient unit (IPU1) on 12 April 2013 following a serious suicide attempt by hanging. He died the next day after being struck by a train. Critical deficiencies were identified in his clinical management: a nursing risk assessment completed at 1.45pm on 13 April identified multiple high risks including suicide/self-harm and absconding, yet the patient remained on Level 2 (30-minutely) observations rather than Level 3 (continuous or specialling) observations as required by the Observation Guideline. The risk assessment was not reviewed collaboratively with a senior clinician. When the patient stated he had "nothing to live for", this significant statement was not communicated to nursing unit managers who would have escalated care. While the inquest found the death itself was not preventable given its impulsive nature, suboptimal compliance with risk assessment and observation guidelines represented missed opportunities for therapeutic engagement.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- inadequate level of observation despite high-risk assessment
- non-compliance with Risk Guideline regarding collaborative risk assessment
- failure to escalate level of observation from Level 2 to Level 3 as required by Observation Guideline
- communication failure regarding patient statement 'nothing to live for'
- lack of documented clinical rationale for departure from Observation Guideline
- absence of therapeutic engagement with a patient refusing cooperation
- inadequate supervision of graduate nurse
Coroner's recommendations
- The Department of Health and Human Services consider the feasibility of establishing long-term residential, rehabilitation-focused mental health treatment facilities that are appropriately resourced to provide intensive care and meet demand for such services in the Victorian community
Full text
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.