Finding into death of Edward Timothy Peterson

25y · Male·Head injury sustained on impact with a train

Edward Timothy Peterson, aged 25, was involuntarily admitted to Maroondah Hospital's psychiatric unit on 11 February 2021 with first episode psychosis. Clinical care by psychiatrist Dr C. was appropriate: medications were adjusted following prior non-compliance, regular reviews occurred, and observation levels were modified based on clinical improvement. On 22 February 2021, after reassurance about discharge planning, Ned expressed anxiety about leaving and absconded by using a chair to scale the 2.8-metre courtyard wall. The student nurse immediately escalated the concern, but intervention came too late. His subsequent movements are unknown; he died by suicide on railway tracks at Frankston that evening. The coroner accepted Eastern Health's concessions that the courtyard wall fell short of recommended heights (3.4–4.5m) and a dedicated security guard should have been deployed. Since implementing a courtyard security guard, no further wall-scaling absconding has occurred.