Deceased
Edward Timothy Peterson
Demographics
25y, male
Date of death
2021-02-22
Finding date
2026-05-19
Cause of death
Head injury sustained on impact with a train
AI-generated summary
Edward Timothy Peterson, aged 25, was involuntarily admitted to Maroondah Hospital's psychiatric unit on 11 February 2021 with first episode psychosis. Clinical care by psychiatrist Dr C. was appropriate: medications were adjusted following prior non-compliance, regular reviews occurred, and observation levels were modified based on clinical improvement. On 22 February 2021, after reassurance about discharge planning, Ned expressed anxiety about leaving and absconded by using a chair to scale the 2.8-metre courtyard wall. The student nurse immediately escalated the concern, but intervention came too late. His subsequent movements are unknown; he died by suicide on railway tracks at Frankston that evening. The coroner accepted Eastern Health's concessions that the courtyard wall fell short of recommended heights (3.4–4.5m) and a dedicated security guard should have been deployed. Since implementing a courtyard security guard, no further wall-scaling absconding has occurred.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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40y · Male·Unascertained
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Source and disclaimer
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