Finding into death of David Bramwell Van Vledder

48y · Male·Drowning

A 48-year-old man with depression, problematic alcohol use, and recent onset paranoid ideation and auditory hallucinations presented twice to the Emergency Department on the morning of his death. Despite expressing suicidal intent with specific plans on first presentation, he left after being triaged for mental health assessment. He re-presented within hours, was deemed not to meet Mental Health Act criteria for involuntary treatment, and was planning medical admission for investigation and alcohol detoxification. While awaiting assessment, he asked to leave briefly for a cigarette as a voluntary patient. He left the hospital and within 40 minutes had jumped from a pier and drowned. Key clinical learning: the failure to assess nicotine dependence at triage meant clinicians could not recognise that his request for a cigarette was inconsistent with his reported non-smoking status, which may have alerted them to his true intent to abscond. Early assessment and management of nicotine dependence in psychiatric emergency presentations may reduce the risk of patients leaving against medical advice.