Inquest into the Death of Martin Carl QUITERIO

59y · Male·Multiple injuries

Martin Carl Quiterio, a 59-year-old man with longstanding schizophrenia and suspected autism spectrum disorder, died on 3 January 2024 when he jumped from the 14th floor of a car park in West Perth. He had been discharged five days earlier on a Community Treatment Order following a 45-day hospital admission. On the morning of his death, after receiving a phone call about an upcoming CTO review, he visited the car park and contemplated suicide. His support coordinator and mental health case manager visited later that morning, conducted appropriate risk assessments, and found him future-focused with adequate safety planning. Hours later, he returned to the car park and jumped. The coroner found all risk assessments were adequate and care was appropriate. However, significant systemic gaps were identified: lack of public health autism diagnostic services and failure to communicate his discharge to family. Two recommendations address establishing a neuropsychiatric consultation service and carer support workers in mental health units.