Inquest into the Death of Paul STRANGE

30y · Male·ligature compression of the neck (hanging)

Paul Strange, aged 30, died by suicide through ligature compression of the neck eleven days after discharge from Royal Perth Hospital (RPH) for depression with chronic suicidality. He had a documented history of multiple suicide attempts by strangulation and was initially assessed as high risk. Critical clinical failures included: failure to document a safety plan despite high-risk status; inadequate family involvement despite demonstrated protective factors and family requests; failure to enact discharge referrals to community mental health services; discharge without any follow-up arrangements; and failure to provide family with basic safety information about post-discharge vulnerability. A medication change occurred four days prior to discharge despite fluctuating mental state. The deceased was not detected to be taking prescribed quetiapine at time of death, worsening untreated anxiety and impulsivity. The coroner found care suboptimal but could not conclusively establish preventability, noting suicide's inherent unpredictability while emphasising systemic failures in discharge planning, documentation, and family engagement.