Coronial
VICcommunity

Finding into death of Mark Beames

Deceased

Mark Beames

Demographics

44y, male

Date of death

2014-09-04

Finding date

2020-05-07

Cause of death

Unascertained

AI-generated summary

Mark Beames, a 44-year-old Aboriginal man with epilepsy, acquired brain injury, and alcohol dependency, disappeared on 4 September 2014 from Swan Hill, Victoria. He had recently been discharged from hospital after self-discharge and was receiving mental health support. Despite comprehensive police investigations including ground, aerial and underwater searches over five years, his body was never located. The coroner determined he died on or shortly after 4 September 2014, with cause of death unascertained. Key clinical lessons include the importance of structured follow-up after hospital discharge for vulnerable patients with complex needs, ensuring medication compliance in patients with epilepsy and substance use disorders, and coordinated care across mental health, addiction services and primary care for patients at risk.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Contributing factors

  • Self-discharge from hospital against medical advice
  • Non-compliance with epilepsy medication
  • Alcohol misuse and intoxication
  • Acquired brain injury
  • Socioeconomic disadvantage and housing instability
  • Mental health vulnerability with suicidal ideation
  • Poor engagement with follow-up appointments and services
Full text

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