Finding into death of James Leslie Kuti

16y · Male·Multiple injuries as a result of high speed impact (train)

James Kuti, a 16-year-old in child protection care with schizophrenia and cannabis use, died by suicide when he jumped in front of a train. He was receiving comprehensive mental health care from Southern Health's Early Psychosis Service and was on appropriate antipsychotic medication (intramuscular Resperidone depot injections) with therapeutic levels confirmed post-mortem. The Coroner's Prevention Unit review found the mental health and protective services provided were comprehensive, appropriate, with good inter-agency communication and medication adjustments made when his mental health deteriorated. The coroner found his care appropriate and made no preventability recommendations or adverse findings regarding clinicians.