Finding into death of Gwyn Pugh

63y · Male·Incised injuries to the neck and upper limbs

Gwyn Pugh, a 63-year-old man with longstanding bipolar affective disorder, died by suicide on 26 October 2022. He had been hospitalized for depression in April-May 2022 and received electroconvulsive therapy. Post-discharge, he disengaged from psychiatric care in July 2022, ceased prescribed medications, and self-prescribed cannabis oil. His community mental health service discharged him in September 2022. A post-mortem neuropathology examination revealed stage 3 chronic traumatic encephalopathy (CTE), likely resulting from repeated head trauma during his Australian rules football career. The coroner found a connection between CTE and his mental health deterioration. Clinical lessons include the importance of proactive follow-up when patients disengage from care, medication non-adherence monitoring, and awareness of CTE as a potential contributing factor to psychiatric symptoms and suicide risk in former athletes with head injury history.