Finding into death of Justin Patrick Crome
Deceased
Justin Patrick Crome
Demographics
39y, male
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.
Specialties
Error types
Contributing factors
- inadequate follow-up after ED presentation with expressed suicidal ideation
- failure to escalate multiple missed psychiatric appointments
- lack of contact with patient in 4 weeks prior to death
- ineffective communication of police information regarding arrest circumstances to treating team
- missed opportunity to assess deterioration (isolation, giving away possessions, reported fighting, anger at home)
- reliance on single letter offering appointment rather than proactive outreach after ED presentation
- no discussion with treating psychiatrist when three appointments missed in four weeks
Coroner's recommendations
- St Vincent's Mental Health embed into its relevant policies and procedures a requirement for case managers to escalate to a psychiatrist when a patient in community care: misses multiple consecutive appointments; and has not been recently reviewed by their case manager, psychiatric registrar, or psychiatrist
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