Inquest into the death of Ross MARTIN

56y · Male·acute pentobarbitone toxicity

Ross Martin, a 56-year-old man with a long history of depression, died from acute pentobarbitone (Nembutal) toxicity obtained online, combined with toxic levels of zopiclone, less than two weeks after premature discharge from involuntary mental health care. After two suicide attempts in July and August 2016, the psychiatric team made critical deficiencies in the discharge decision on 1 September 2016. Dr K. and Dr S. failed to conduct a proper review of Mr Martin's extensive medical history, particularly the detailed Form 1 documenting deliberate, elaborate suicide planning. The decision was based largely on Mr Martin's misleading account and limited cross-sectional assessment without accessing prior records or collateral information. Police also returned a parcel of zopiclone to Mr Martin on the morning of his death without proper regard to suicide risk. Clinicians should thoroughly review historical records before discharging involuntary patients, particularly when family members provide concerning collateral information suggesting deception, and consider the risk posed by returning potentially lethal drugs to acutely suicidal individuals.