Mental Health patient

Female·multiple injuries due to a fall from height (suicide by jumping from multi-storey car park)

A woman with major depressive disorder and psychotic features died by suicide at a shopping centre car park on 21 September 2004, six days after admission to Belmont Private Hospital under an involuntary treatment order. She had attempted suicide in July 2004 and was discharged on 30 August 2004 against medical advice, declining ECT and antipsychotic medication despite being delusional and at risk. On 19 September she deteriorated acutely with suicidal ideation and was admitted to Princess Alexandra Hospital then transferred to Belmont. Critical failures included: a nursing unit manager reducing observation frequency from 15 to 30 minutes without doctor approval; unclear communication about 'nil leave' restrictions; an unaccompanied walk in hospital grounds that falsely reassured staff; and late detection of her absence. Clinicians should document observation levels clearly, ensure consistent understanding of restrictions across all staff, implement formal suicide risk assessment protocols, and maintain vigilant monitoring despite apparent compliance.