Coroner's Finding: BARTON Stephen John

43y · Male·blunt neck trauma from compression of the neck

Stephen John Barton, aged 43, died from blunt neck trauma inflicted by roommate Lindon Sekrst in a psychiatric ward. Both were detained patients under Mental Health Act orders. Sekrst, a 23-year-old with paranoid ideation, had been in ED for 3 days before admission to the open ward. He was placed in shared accommodation with Barton due to bed availability despite concerns about paranoia. The coroner found dual room accommodation—unique to this facility—was a contributing factor to the death. The case highlights that psychiatric patients with paranoid ideation should not be placed in shared rooms, clinicians should more thoroughly explore paranoid statements, and adequate staffing/single-room accommodation are essential safety measures.