Inquest into the Death of Mark Warton BENNETT-ROBERTSON

25y · Male·ligature compression of the neck (hanging)

A 25-year-old man with dexamphetamine-induced psychosis died by suicide while an involuntary psychiatric patient. He was transferred from a locked to an open ward on 19 April 2013 after appearing to improve clinically. His psychiatrist was not consulted about this decision by the medical officer. He absconded on 21 April 2013 and was found hanging two days later. The coroner found the ward transfer reasonable in foresight given his apparent clinical improvement, compliance with medication, and regular escorted leave without incident. However, the deceased's sister reported he remained delusional during phone calls and may have been deceptive to staff. A key stressor—learning his father could not accommodate him—was unknown to treating staff. The coroner noted that current policy now requires immediate police notification for absconding patients at risk of mental state deterioration due to medication non-compliance.