Finding into death of Jamie Peter Nisbet

47y · Male·Compression of the neck arising from hanging

47-year-old man with antisocial personality disorder, psychosis, and methamphetamine use died by hanging. He presented to emergency departments on 10, 19, and 20 September 2021 with suicidal ideation, auditory hallucinations, and psychotic symptoms. Although assessed by psychiatry registrar Dr D. on 19 September, she concluded his presentation was non-genuine and he was seeking admission to avoid court. He was not admitted. Following a failed telehealth appointment on 20 September where he was verbally abusive to Dr E., the community mental health team discharged him on 21 September without escalating concerns to senior staff, without directly contacting his GP, and without family engagement. The coroner found clinical management deficiencies but not causally related to death. Key lessons: escalate complex cases to senior staff, ensure direct GP communication at discharge, contact family before discharge, and arrange safer assessment locations when therapeutic relationship is compromised.