Coroner's Finding: KAY Damian

38y · Male·Multiple injuries

Damian Kay, aged 38, died from multiple injuries after jumping from the 16th floor of a hotel on 22 September 2010, with a blood alcohol concentration of 0.71%. The death occurred in the context of recent relationship breakdown and unresolved grief following the loss of his wife and children in the 2005 Wangary bushfire. Mr Kay presented to the Emergency Department via police after writing a three-page suicide note detailing asset distribution. A junior RMO, Dr N., assessed him after only 10-15 minutes without reading the suicide note, without utilising available collateral history including a prior suicide attempt, and without consulting senior colleagues despite these resources being readily available. The coroner found multiple significant clinical omissions contributed to his discharge without appropriate mental health follow-up or detention, resulting in preventable loss of life within hours.