Deceased
Mr BB
Demographics
56y, male
Date of death
2018-12-18
Finding date
2021-03-30
Cause of death
Hanging
AI-generated summary
A 56-year-old man with a long history of bipolar affective disorder and alcohol misuse died by hanging between 18–20 December 2018. He presented to hospital on 16 December after expressing suicidal intent (plan to overdose in Bali following relationship breakdown). He was assessed by a consultant psychiatrist on 17 December, found to lack current suicidal ideation and not meeting criteria for compulsory admission, and discharged for community follow-up. Key clinical lessons: collateral information from family was not directly obtained before discharge despite being available on file and the psychiatrist's failed attempt to contact his wife; the discharge plan was not discussed with his family despite their availability at hospital; and alcohol intoxication and medication (benzodiazepines, antipsychotic) may have affected his presentation during assessment. The coroner found the Mental Health Act threshold for compulsory treatment appropriately applied but recommended updating guidelines to require family contact before discharge in cases where suicide risk minimisation is suspected.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
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