Coroner's Finding: SAID David Patrick

38y · Male·multiple injuries

A 38-year-old man with chronic disorganised schizophrenia died from multiple injuries after jumping or falling from a dam wall while under police observation. He had been recently distressed following his family dog's death, which he had stated would trigger suicidal ideation. Police were attempting to detain him under the Mental Health Act when he went over the wall. A case conference three weeks prior had discussed management of his anticipated reaction to the dog's death, with the family preferring home monitoring rather than preventive detention. Police negotiators and specialist tactical officers were present; officers determined they could not safely retrieve him before he jumped. The coroner found police conducted appropriate and compassionate management of an impossible situation. This case highlights the challenges in predicting and preventing suicide in mentally ill patients, even with advance planning and professional involvement.