An 85-year-old man with myelodysplasia and severe hip pain from an ischiorectal abscess died from incised wrist wounds sustained in a nursing home while in palliative care. He had expressed wishes to die, discussed euthanasia, and resisted resuscitation efforts. The coroner found care was appropriate given his circumstances. However, the case highlights gaps in suicide risk assessment and mental health support for palliative and aged care patients. Clinical lessons include: recognising suicide risk in older patients with chronic pain and functional decline; ensuring adequate psychosocial assessment alongside pain management; maintaining vigilance despite palliative care focus; and considering environmental factors (isolation from family due to COVID restrictions) contributing to hopelessness. The coroner made recommendations for improved suicide risk training, mental health service access pathways, and psychosocial support protocols in aged care settings.
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