Finding into death of Jamie Andrew Kowalewsky

27y · Male·Global cerebral ischaemic injury in the setting of hanging

Jamie Kowalewsky, a 27-year-old with long-standing mental health issues including depression, substance abuse (ICE and cannabis), and previous suicide attempt, was voluntarily admitted to a low dependency psychiatric unit on 24 April 2018. Over four days, he was assessed as medium risk despite expressing suicidal and homicidal ideation. On 29 April 2018, after becoming upset during a phone call with his mother, he hanged himself using a bed sheet attached to a toilet door frame within approximately 30 minutes of last observation. Clinical experts disagreed about risk stratification and observation frequency. The coroner found psychiatric management was reasonable and appropriate, noting risk assessment is fluid and difficult to predict. No clear, cogent evidence of increasing risk warranting higher dependency admission was identified. The death was not found to be preventable.