Finding into death of XY

58y · Male·Combined drug toxicity (eucalyptus oil, alcohol, venlafaxine, quetiapine, propranolol, diazepam)

A 58-year-old man with chronic depression, anxiety and personality disorders died from combined drug toxicity (eucalyptus oil, alcohol, venlafaxine, quetiapine, propranolol, diazepam) after presenting to ED with suicidal ideation and overdose. Discharged the following day despite refusal to engage with mental health services, he absconded from his supported residential service and was found deceased. The coroner found Austin Health's psychiatric assessment and management suboptimal, highlighting failures to: utilise relapse prevention plans, anticipate continued refusal to engage, escalate to psychiatrist review, or establish clear safety planning with SRS staff. The mental health service inappropriately delegated risk assessment to non-clinical SRS staff without expertise, training or clear escalation criteria. Recent Austin Health process improvements are acknowledged but do not adequately address the interface between mental health services and supported residential services during acute deterioration.