Finding into death of Frank (Francesco) Sette

72y · Male·Cranial fracture and intracranial haemorrhage from self-inflicted fall

Frank Sette, a 72-year-old man with longstanding schizophrenia, died from a cranial fracture and intracranial haemorrhage sustained when he deliberately threw himself backwards onto the floor of a psychiatric ward. He was an involuntary patient in the High Dependency Unit experiencing acute psychotic relapse with command hallucinations. Clinical staff were present and responding appropriately to his acute agitation and behaviours. The fall occurred unexpectedly despite close supervision and 15-minute visual observations. Post-mortem examination confirmed a right parietal fracture with subdural haemorrhage and midline shift. The coroner found the incident could not have been reasonably prevented. The case highlights the challenges of managing acute psychosis with severe agitation and self-harm risk in involuntary patients, and the importance of continued close observation despite preventive measures.