Coroner's Finding: FELSTEAD Christopher John

33y · Male·carbon monoxide poisoning consistent with inhalation of car exhaust fumes

A 33-year-old man with major depressive disorder and multiple suicide attempts died by carbon monoxide poisoning after premature discharge from psychiatric inpatient care. He was admitted to Lyell McEwin Health Service on 16 February 1999 following a serious overdose, diagnosed with major depressive disorder by an experienced registrar, and placed on Ward 1G. However, Dr D. discharged him after only one day without consulting the admitting registrar or the referring private psychiatrist who had explicitly warned of serious suicide risk. The discharge occurred despite clear clinical indicators for longer admission: multiple recent overdoses, previous suicide attempt by motor vehicle, melancholic depression, and documented high-risk features. The coroner found the discharge inappropriate and occurring within a broader pattern of inadequate treatment. Critical failures included failure to recognize severity, lack of inter-clinician communication, and premature community discharge without adequate follow-up arrangements.