Inquest into the death of CC

33y · Male·Hanging

CC, a 33-year-old First Nations man with methamphetamine-induced bipolar disorder and psychosis, was admitted to the High Dependency Unit at Nepean Hospital on 7 June 2022 under involuntary mental health detention. Over eight days, he received appropriate psychiatric care including antipsychotics, mood stabilisers and benzodiazepines at observation level 3 (30-minute observations). On 14 June, nursing staff discovered CC had torn a towel to make shoelaces; a second ripped towel was found on 15 June morning. These incidents, indicating potential self-harm risk, were documented on a handover board but not recorded in medical notes or communicated to treating doctors. At 2.20pm on 15 June, CC was found hanging in his ensuite bathroom using a ligature made from bedding. Despite prompt CPR, he died. The coroner found no criticism of clinical management. Key lessons: implement systematic flagging of significant clinical observations in electronic medical records so treating teams are alerted to potential risk indicators; eliminate functional ligature points from psychiatric ward doors as priority environmental safety measure.