Coronial
VIChospital

Finding into death of S J

Deceased

SJ

Demographics

24y, male

Coroner

Deputy State Coroner Paresa Spanos

Date of death

2016-09-22

Finding date

2023-01-18

Cause of death

Injuries sustained in fall from height

AI-generated summary

SJ, a 24-year-old man with recently diagnosed Stage 4B non-Hodgkin lymphoma and pre-existing depression managed by Orygen Youth Health, died by suicide on 22 September 2016 by jumping from the seventh-floor rooftop garden of Peter MacCallum Cancer Centre. Despite a history of depression with previous suicidal ideation, SJ was assessed as low-risk by his mental health team and appeared clinically stable and engaged with staff on the morning of his death. The coroner found no evidence of want of care by either Orygen or PMCC. Key clinical lessons include: the importance of timely clinical handover between mental health and cancer services (though in this case, delays did not affect outcome); proactive mental health screening tools for cancer patients; and that metoclopramide carries rare but recognised psychiatric risks that warrant explicit risk-benefit consideration in patients with depression, though no causal link was established in this case. Most significantly, the coroner noted that suicide in low-risk individuals remains unpredictable and that SJ's death was likely an impulsive act with no preceding indication to clinicians.

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

Specialties

psychiatryhaematologyoncologygeneral practice

Error types

communicationdelay

Drugs involved

metoclopramidefluoxetinediazepamtemazepamzopicloneloperamideparacetamol

Clinical conditions

major depressionanxietydiffuse large B-cell non-Hodgkin lymphoma stage 4Bsepsispneumoniapleural effusionneutropaenia

Contributing factors

  • Pre-existing major depression with history of suicidal ideation
  • Recent cancer diagnosis and chemotherapy commencement
  • Acute infection (sepsis) with fever, diarrhoea, vomiting, and fatigue
  • Disrupted sleep overnight before death
  • Access to unsecured furniture on rooftop garden allowing climbing of glass barrier
  • Possible delayed recognition of acute change in mental state

Coroner's recommendations

  1. Clarification of clinician responsibility and recording of progress of actions at clinical review meetings (implemented by Orygen)
  2. Expansion of handover forms to include clinical handover to other medical clinicians and services involved in Orygen client care (implemented by Orygen)
  3. Securing of portable furniture on hospital rooftop to prevent use as climbing aids (implemented by PMCC)
  4. Review of medical handover process for patients transferring from precinct partner hospitals to ensure all relevant past medical and mental health history is communicated at time of handover (implemented by PMCC)
  5. Referral of all patients with history of mental ill health or current mental illness to psycho-oncology program if appropriate (implemented by PMCC)
  6. Raised awareness of need for prompt referral to psycho-oncology department (implemented by PMCC)
  7. Implementation of electronic Admission Transfer Document that flags behavioural risk including self-harm and suicide risk with guidance on escalation (implemented by PMCC)
  8. Education of junior medical staff about mental health deterioration during cancer treatment (implemented by PMCC)
Full text
Official source Archived copy

Related cases from VIC

VICcommunity2026-05-07

Finding into death of Elizabeth Susan Edwina Ferris

44y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest in the setting of p…

Elizabeth Ferris, a 44-year-old woman with schizoaffective disorder and polysubstance use disorder, died from hypoxic ischaemic encephalopathy following cardiac arrest in the setting of presumed drug toxicity. She was fo…

psychiatryintensive carediagnosticcommunicationheroin
VIC2026-04-22

Finding into death of Natasha Stojkoski

38y · Female·Multiple injuries sustained when struck by a train

Natasha Stojkoski, a 38-year-old sales assistant at The Good Guys, sustained a workplace injury in October 2018 involving a Work Assisted Vehicle incident affecting her back, shoulders and neck. Subsequently, she reporte…

psychiatryoccupational and environmental healthsystemcommunicationescitalopram
VIChome2026-04-17

Finding into death of Harrison William Ladd

25y · Male·Combined drug toxicity

Harrison William Ladd, 25, died from combined drug toxicity involving clonazepam, dexamphetamine, codeine, diazepam and pholcodine. He had complex mental health and substance use disorder requiring specialist addiction c…

general practicepsychiatrymedicationcommunicationclonazepam

Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.