Inquest into the Death of Marshall, Tracy Margaret

54y · Female·unascertainable

Tracy Margaret Marshall was a 54-year-old woman admitted to Nickol Bay Hospital on 20 February 2011 after reporting suicidal ideation and three suicide attempts. She presented with signs of psychotic illness including bizarre behaviour, religious ideation, and visual phenomena, but was not prescribed antipsychotic medication. She left the hospital voluntarily at 6:19am on 21 February 2011 without being discharged. Her vehicle was later found abandoned in Millstream-Chichester National Park with an empty Valium blister pack inside. Despite extensive searches, her body was never found. The coroner found her death was likely on or about 21 February 2011 but made an open finding as to cause. Key clinical lessons: early recognition and appropriate pharmacological treatment of psychotic symptoms, need for adequate psychiatric assessment and involuntary admission protocols, and importance of secure observation in patients with acute suicidality.