Lorna Silvester, a 27-year-old woman with depression and suicidal ideation, died by hanging on 18 January 1999 while on approved leave from Graylands Hospital. She had been admitted involuntarily on 13 January after presenting with depression, suicidal intentions, and aggression. Despite her documented suicidal risk, she was granted day leave on 14 January by the Consultant Psychiatrist and did not return. She was permitted to sleep on the rear patio of premises in Perth. On the morning of 18 January, she telephoned stating she would kill herself and was found hanging approximately 45 minutes later. The coroner found death by suicide. This case highlights risks associated with granting leave to involuntary psychiatric patients with active suicidal ideation and the importance of appropriate supervision and risk assessment in mental health settings.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
psychiatry
Error types
communicationsystem
Drugs involved
haloperidolclonazepam
Clinical conditions
depressionsuicidal ideationsolvent abuse
Contributing factors
Active suicidal ideation at time of admission
Grant of day leave to involuntary patient with documented suicidal risk
Inadequate supervision during approved leave
Patient did not return from leave as expected
Approval of leave despite recent re-admission for suicidal intentions
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.