Finding into death of Ingrid Mary Marr

30y · Female·Hanging

A 30-year-old woman with borderline personality disorder, substance abuse history, and exposure to multiple family suicides (father, close friend, partner's mother) presented to Emergency Department after self-harm and suicidal ideation on 11 August 2016. She was assessed by psychiatric nursing staff, denied active suicidal intent, and was discharged with safety planning (staying at mother's farm next day) and two 30mg oxazepam tablets. She died by hanging approximately 6-7 hours post-discharge. The coroner found no evidence of clinical error in the ED assessment or discharge decision. The case highlights suicide risk in patients with prior exposure to suicide deaths and the importance of comprehensive risk assessment in this vulnerable population.