Inquest into the Suspected Death of Paul Clifford YORK

AI-generated summary

Paul Clifford York, 45, disappeared from Petrudor Rocks National Park on 10 November 2011 and is presumed dead. He had a long history of depression, suicidal ideation, and previous suicide attempts by hanging and overdose. He was sexually abused as a teenager, struggled with substance abuse, and had recently been admitted to Joondalup Health Campus for psychiatric assessment after expressing suicidal intent. He was discharged after 2 days with antidepressant medication and arranged community mental health follow-up. Four days later, he disappeared. Evidence at the scene (ladder, rope, broken branches) suggested a suicide attempt, but his body was never found. The coroner could not determine the cause of death. Key clinical lesson: the rapid discharge of a high-risk patient with severe ongoing psychosocial stressors after only 48 hours, despite ongoing suicidal ideation and significant risk factors, may warrant reconsideration of risk stratification and discharge planning protocols.

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