Coronial
WAmental health

Inquest into the Death of Steven Charles Indich

Deceased

Steven Charles Indich

Demographics

20y, male

Date of death

1998-11-13

Finding date

2000-01

Cause of death

Ligature Compression of the Neck (Hanging)

AI-generated summary

Steven Charles Indich, a 20-year-old Aboriginal man with schizophrenia and a long history of psychotic symptoms, violent behaviour and substance abuse, died by suicide in Smith Ward at Graylands Hospital on 13 November 1998. He was admitted involuntarily after assaulting his brother and father whilst acutely psychotic. Despite appropriate antipsychotic medication and close observation during his 3-day admission, he was not assessed as suicidal and no evidence of suicidal ideation was documented during this final admission. He hanged himself with a belt from his wardrobe rail approximately 10 minutes after last being seen by nursing staff. The coroner found the death was wholly unexpected given the clinical assessment at the time, but noted the deceased had long-standing concerns about involuntary hospital admission stemming from lack of insight into his condition, traumatic police-facilitated admission as a 15-year-old, stigma, and paranoid fears. The coroner recommended cultural awareness training for nursing staff and environmental improvements to reduce hanging points and create a less intimidating ward atmosphere for Aboriginal patients.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

psychiatryintensive caregeneral practiceaboriginal health

Error types

system

Drugs involved

haloperidolclonazepamthioridazinemarijuanaalcoholLSD

Clinical conditions

schizophreniadelusional disorderpsychosisparanoid delusionssubstance abuse

Contributing factors

  • Schizophrenia with paranoid delusions
  • Substance abuse (alcohol and drugs)
  • Acute psychosis
  • Violent behaviour
  • Lack of insight into mental illness
  • Distress about involuntary detention
  • Stigma surrounding mental health
  • Absence of documented suicidal ideation despite risk factors
  • Accessible hanging points in wardrobe

Coroner's recommendations

  1. Remove hooks and rails from wardrobes in wards to prevent hanging points
  2. Take further steps to reduce access by patients to possible hanging points
  3. Provide training to nurses responsible for dealing with patients at Graylands Hospital in relation to Aboriginal Cultural issues
  4. Improve the physical environment at wards such as Smith Ward
  5. Encourage the display of appropriate works of art prepared by patients themselves where practicable
  6. Establish an Aboriginal Cultural Centre committed to securing culturally appropriate activities for Aboriginal people with psychiatric disability
  7. Encourage the Aboriginal Community to participate in ongoing activities to promote awareness and understanding within the Aboriginal community about mental illness
Full text
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