Sarah Jane Rutherford, a 28-year-old with bipolar affective disorder and schizophrenia, died by suicide on 27 December 2009 after falling from a bridge onto the Mitchell Freeway while on leave from Graylands Hospital. She had been admitted on 3 December 2009 following medication non-compliance and suicidal ideation. Her condition improved significantly with antipsychotic medication; she was discharged to family care on 23 December with a seven-day prescription and expected discharge within days. The coroner found the treatment and care at Graylands was reasonable and appropriate. However, the case highlights risks of symptom masking by patients with schizophrenia—her aunt had expressed concerns about the deceased's ability to conceal her mental state 10 days before death. The deceased likely stopped her medication in the days before suicide, which had previously precipitated deterioration. Key clinical lessons include: maintaining vigilance for non-compliance in patients with psychotic disorders on leave; recognising that clinical stability may mask ongoing suicidal intent, particularly when family members raise concerns; and considering more frequent review intervals when transitioning to community care.
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