Finding into death of Mr P
Deceased
Mr P
Demographics
71y, male
Date of death
2019-07-01
Finding date
2022-07-14
Cause of death
Exsanguination from incised wounds to the neck and wrist
AI-generated summary
A 71-year-old man with bipolar disorder, depression, alcohol addiction, and cirrhosis died by suicide via exsanguination from neck and wrist lacerations. He had stopped psychiatric medications in 2017 and was managed by his GP. In June 2019, he presented with increased stress, alcohol intake, and suicidal ideation (denied intent). Test results from 19 June were reviewed by his doctor on 25 June, but the clinic failed to generate an expected nurse call to arrange follow-up discussion of results, though the doctor believed an appointment existed for 1 July. The coroner highlighted that proactive follow-up of older men with suicidal ideation and depression is essential, and recommended the RACGP promote timely follow-up or tertiary referral for at-risk patients.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- History of bipolar disorder and depression
- Alcohol addiction and increased alcohol intake in preceding months
- Cirrhosis of the liver with portal hypertension
- Cessation of psychiatric medications in 2017
- Suicidal ideation disclosed to family but denied to doctors
- Failure to arrange timely follow-up appointment after test results reviewed on 25 June 2019
- Lack of proactive follow-up by primary care clinic
- Perceived financial stress
Coroner's recommendations
- The Royal Australian College of General Practitioners should highlight to Fellows and members the higher prevalence of suicide in males compared to females, particularly as men age.
- The College should recommend to Fellows and members the desirability of proactive timely follow-up of males presenting with suicidal ideation, history of such ideation, indicators of depression, or history of suicide attempts.
- If timely follow-up is unavailable, patients should be referred to an appropriate service that can facilitate such timely follow-up.
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