Coroner's Finding: HEATLEY Alan Forsyth

17y · Male·cranial and facial trauma

A 17-year-old male with acute schizophrenia died from cranial and facial trauma after running off a 15.6-metre cliff during a psychotic episode. Hours before, he had been seen by a trainee psychologist who failed to recognize clear psychotic symptoms—including delusions about being Jesus, grandiose ideas, and perceptual distortions—and attributed concerning statements to manipulation. The psychologist did not document findings, declined to contact parents despite the adolescent's minor status, and made no urgent referral. Critical clinical lessons include: recognizing early psychotic symptoms and loss of perceptual constancy; documenting all assessments thoroughly; not dismissing concerning statements as manipulation; understanding the obligation to breach confidentiality and contact family when a minor presents with acute psychiatric symptoms; and establishing clear referral pathways to emergency mental health services (ACIS). The case demonstrates significant gaps between psychology and psychiatry liaison and the dangers of under-recognizing acute psychosis in young people.