Finding into death of Paul Simon Taouk

40y · Male·Carbon Monoxide Poisoning

Paul Taouk, a 40-year-old with schizophrenia and substance use disorder, died from carbon monoxide poisoning after absconding from a community mental health clinic on 23 December 2015. He had been assessed as unsafe and depressed, requiring inpatient admission, but left the clinic upset before transportation could be arranged. A welfare check was requested via Triple Zero, but police located him at his address only after patrolling the area without knocking on the door. He had hired generators and subsequently died in his vehicle in a car park with a generator running. Clinical lessons include: (1) improved communication protocols between mental health services and police are needed when patients abscond; (2) welfare checks should include direct contact with residents, not just area patrols; (3) clearer guidance on when both urgent police attendance and formal apprehension procedures apply; and (4) systematic follow-up on welfare check outcomes to health services. No clinical failures in the mental health assessment or the decision to admit were identified.