Finding into death of S J
Deceased
SJ
Demographics
24y, male
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.
Error types
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
- Clarification of clinician responsibility and recording of progress of actions at clinical review meetings (implemented by Orygen)
- Expansion of handover forms to include clinical handover to other medical clinicians and services involved in Orygen client care (implemented by Orygen)
- Securing of portable furniture on hospital rooftop to prevent use as climbing aids (implemented by PMCC)
- 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)
- Referral of all patients with history of mental ill health or current mental illness to psycho-oncology program if appropriate (implemented by PMCC)
- Raised awareness of need for prompt referral to psycho-oncology department (implemented by PMCC)
- Implementation of electronic Admission Transfer Document that flags behavioural risk including self-harm and suicide risk with guidance on escalation (implemented by PMCC)
- Education of junior medical staff about mental health deterioration during cancer treatment (implemented by PMCC)
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