Finding into death of N A
Deceased
NA
Demographics
59y, male
Date of death
2021-10-11
Finding date
2024-11-13
Cause of death
compression of the neck secondary to hanging
AI-generated summary
A 59-year-old man with treatment-resistant depression, anxiety, and suicidal ideation died by hanging while on weekend leave from psychiatric care. He had been hospitalised four times in 2021 and was receiving electroconvulsive therapy. On discharge morning, he disclosed suicidal thoughts to his psychiatrist but was offered weekend leave as an alternative to full discharge. Clinical staff attempted but failed to contact his wife to inform her of the discharge plan and recent suicidal ideation. While on leave, his mood deteriorated but he denied suicidal intent during a Monday morning review. He died by suicide later that day. The coroner found the psychiatrist's decision to allow leave was reasonable given available information, though communication with his wife—a key protective factor—was suboptimal. The coroner noted this communication failure was unlikely to have prevented his death but represented a missed opportunity for a more comprehensive assessment of his mental state.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- treatment-resistant major depressive illness
- recurrent suicidal ideation
- panic disorder and generalised anxiety disorder
- survivor guilt and shame following twin brother's suicide in 2020
- work-related trauma and post-traumatic mental health decline from 2007
- avoidant behaviour and poor insight into condition
- failure to contact wife prior to discharge to ensure awareness of suicidal ideation
- lack of collateral information from wife during weekend leave period
- disclosure of suicidal thoughts on morning of discharge not resulting in cancellation of leave plan
Coroner's recommendations
- Encourage the Chief Commissioner of Police to consider provision of ligature cutters to Victoria Police members in the field as a relatively inexpensive, safe and effective tool that could improve timeliness of resuscitative efforts in similar cases
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