Deceased
Justin Patrick Crome
Demographics
39y, male
Coroner
Coroner Paul Lawrie
Date of death
2020-02-13
Finding date
2023-02-24
Cause of death
Injuries sustained in a fall from the Camberwell train station bridge
AI-generated summary
Justin Crome, a 39-year-old man with delusional disorder and schizophrenia, died by suicide after jumping from a railway bridge on 13 February 2020. He had a history of mental illness since 2016, multiple psychiatric admissions, and police contact. Critical clinical lessons include: (1) After ED presentation on 6 February 2020 with expressed suicidal ideation, there was inadequate follow-up contact within 24 hours despite missing three appointments in four weeks; (2) Case managers failed to escalate concerns to treating psychiatrists when patients missed multiple consecutive appointments and had extended periods without review; (3) Police handover information about the actual reason for arrest (breach of intervention order related to psychotic preoccupations) was not effectively communicated to hospital staff, limiting clinical context; (4) Signs of deterioration (isolation, giving away possessions, reported fighting, anger at home) were not adequately assessed. St Vincent's Mental Health has since improved discharge follow-up procedures, but escalation protocols for multiple missed appointments remain inadequate.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
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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…
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…
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