Finding into death of Anthony Lansell Churches

70y · Male·Cyanide Toxicity

Anthony Lansell Churches, a 70-year-old man with a history of substance use and criminal offences, died from cyanide toxicity after absconding from St Vincent's Hospital's Emergency Department. He had been placed on an involuntary psychiatric Assessment Order after expressing suicidal intent during custody assessment. In the ED, he was assessed as calm and cooperative, placed in a high-visibility cubicle without one-to-one observation, and absconded at 3:40pm during the busy afternoon shift changeover. Police were notified but without the critical MHA124 form, they were unaware of urgency. He returned home where he had threatened to ingest cyanide and died before police could gain entry. Key clinical lessons: compulsory psychiatric patients require formal risk assessment and appropriate observation levels; the MHA124 notification form is essential for police prioritisation; high-visibility bed placement alone is insufficient without consistent continuous observation; and shift changes during peak ED periods require enhanced vigilance for at-risk patients.