Coroner's Finding: Lockwood, Shane

45y · Male·Stab wound to the chest, self-inflicted

Shane Lockwood, a 45-year-old man with chronic schizophrenia, died by self-inflicted stab wound in April 2009, approximately two months after discharge from psychiatric hospital on a Community Treatment Order. He was discharged on a complex medication regime requiring fortnightly depot injections at a general practice in George Town, a significant change from his 15-year pattern of receiving medication at the hospital. The coroner found that the Care Plan was not properly implemented: case management relied excessively on telephone contact rather than regular face-to-face meetings, and the case manager did not attend the first depot injection to ensure Mr Lockwood understood the new arrangements. Mr Lockwood experienced multiple practical difficulties accessing his medications, expressed distress about the process, and felt unsupported. The coroner concluded that while these failures cannot be proven to have prevented his death, closer monitoring and personal support would have improved the prospect of a different outcome.