Inquest into the Death of John Vincent KEARNEY

49y · Male·Carbon monoxide toxicity

John Vincent Kearney, a 49-year-old man with a history of depression, anxiety, and a prior suicide attempt 10 years earlier, presented to the ED on 26 March 2010 with suicidal ideation. He was assessed by psychiatric liaison nursing and a psychiatry registrar, admitted overnight to ED observation, and discharged the next morning into his brother's care with community follow-up via the Transitions Program. His wife opposed discharge, believing hospital admission was necessary. Despite appearing to improve post-discharge and being assessed as low-risk by the Transitions Program, he died by carbon monoxide poisoning on 30 March 2010. The coroner found his psychiatric assessment and discharge plan were appropriate and safe, with no preventable clinical failures. However, communication with his wife as a carer could have been improved, and more structured documentation processes (since implemented) would enhance accountability and carer involvement in discharge planning.