Inquest into the Death of Alexander Albert Steinbrenner
Deceased
Alexander Albert Steinbrenner
Demographics
36y, male
Date of death
2004-02-27
Finding date
2005-02-04
Cause of death
Multiple injuries sustained from intentional jump from cliff top
AI-generated summary
Alexander Albert Steinbrenner, a 36-year-old man with schizo-affective disorder, died from multiple injuries sustained when he jumped from an 11-metre cliff at the Roundhouse in Fremantle on 27 February 2004. He was an involuntary patient at Alma Street Centre, Fremantle Hospital, who had absconded from the ward. On the day of his death, he left the ward in an irritable mood and contacted his parents, who attempted to find him accommodation. Unable to secure suitable accommodation and expressing suicidal ideation to paramedics after the jump, he died in the Emergency Department from extensive trauma including subarachnoid haemorrhage, lung contusions, bilateral haemothoraces, and multiple fractures. The coroner found his death was by suicide and concluded the supervision, treatment and care provided by Mental Health Services was appropriate, noting the tension between maintaining therapeutic open ward conditions and restrictive detention for involuntary patients.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Drugs involved
Clinical conditions
Contributing factors
- Schizo-affective disorder with deteriorating course despite medication
- Non-compliance with medication and dietary requirements
- Persecutory delusions and suicidal ideation
- Inability to secure suitable accommodation on day of death
- Frustration with ongoing involuntary admission
- Lactose intolerance and gluten allergy affecting mood and psychotic symptoms
Coroner's recommendations
- South Metropolitan Mental Health Service Policies and Procedure Manual in the area of missing or suspected missing patients could be a little clearer in some of its procedures
Full text
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