Finding into death of Renee Andrea Treen

24y · Female·multiple injuries from jumping off Bulla Road overpass onto Tullamarine Freeway

Renee Treen, aged 24, died by suicide from the Bulla Road overpass while an involuntary psychiatric patient. Critical failures included: inadequate assessment of suicide risk (prior freeway-adjacent behaviour not weighted), delayed notification to police (1.35 hours after absconding), insufficient observation frequency following second absconding episode, and lack of structured monitoring for approved leave conditions. The unit operated under "least restrictive" principles but failed to implement safeguards when clinically indicated. Nicotine withdrawal management was not addressed despite recognised impact on mental state. Clinical lessons: suicide risk assessments must incorporate behaviour proximate to admission; second absconding episodes warrant escalated containment; observation frequencies must increase with risk changes; leave conditions must be clearly documented and monitored; and nicotine dependence requires active management in psychiatric units.