Finding into death of Brett Jeffrey McDonnell
Deceased
Brett Jeffrey McDonnell
Demographics
35y, male
Date of death
2018-01-21
Finding date
2020-12-30
Cause of death
Hanging
AI-generated summary
Brett McDonnell, a 36-year-old man, died by hanging in January 2018 while subject to a Community Corrections Order and facing pending criminal charges. He had a history of depression treated with Pristiq since 2015, but engaged minimally with mental health services despite referrals to psychologists. Key clinical lessons include: the importance of comprehensive mental health assessment in primary care, particularly when patients are evasive about their history; the need for GPs to follow up on previous mental health referrals; and recognition of depression in the context of psychosocial stressors (relationship breakdown, legal issues, financial stress). The Corrections Victoria suicide screening tool was found to be inadequate and administered perfunctorily. His case highlights failures in both primary care continuity and in correctional mental health assessment, though whether earlier intervention would have prevented his death remains uncertain.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Depression with inadequate engagement with mental health services
- Relationship breakdown
- Pending criminal charges and legal stress
- Financial stress related to legal costs
- Recent period of imprisonment
- Inadequate suicide risk screening by Corrections Victoria
- Failure to allocate Advanced Case Manager despite medium risk assessment
- Incomplete assessment by GPs who did not probe history adequately
- Non-engagement with psychological referrals
- Presence of alcohol and methamphetamine in post-mortem toxicology
Coroner's recommendations
- Corrections Victoria should obtain detailed professional advice about the adequacy and effectiveness of the 'Suicide and Self-harm Risk Screening Suite'
- Review qualifications and training of those who administer the screening suite
- Review manner in which the screening suite is administered
- Improve insight into state of mind of those assessed, specifically regarding likelihood of proximate suicide and self-harm risk
- Consider recommending a minimum time-period over which the screening suite ought to be administered
- Implement periodic 'refresher' training for those administering the screening suite
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