Coroner's Finding: DOOMA Renato

36y · Male·Multi-organ failure due to consequences of multiple injuries sustained following motor vehicle collision

A 36-year-old man with chronic treatment-refractory paranoid schizophrenia was involuntarily detained in an acute psychiatric ward after a failed community trial. Despite being a documented high absconding risk, he was transferred from the secure closed ward to an open ward to accommodate more acute patients. Within hours, after receiving PRN medication for agitation, he absconded unnoticed due to inadequate observation practices and was struck by a motor vehicle, sustaining multiple injuries including head trauma. He died 17 days later from multi-organ failure and sepsis. The coroner identified preventable factors: shortage of extended-care beds forcing retention in unsuitable acute facilities, failure to implement documented half-hourly observation protocols, and lack of additional supervision arrangements when moving a known absconding risk to an open ward. Systemic failures in mental health resource allocation and individual staff failures in patient observation contributed to this death.