Finding into death of Marcus William Caldwell

27y · Male·Hanging

Marcus Caldwell, a 27-year-old with well-controlled schizophrenia on clozapine, died by suicide in February 2018. He worked at a pet boarding facility that experienced severe staffing shortages during peak season, resulting in excessive workloads, long consecutive shifts (up to 14 hours), and minimal time off. Despite being psychiatrically stable and compliant with medication, Marcus developed significant workplace stress from December 2017 onwards, characterised by burnout, fatigue, and moral distress—feeling unable to provide adequate animal care due to understaffing. His emotional decline was not consistent with schizophrenia relapse but rather reflected chronic occupational stress. The coroner found that workplace conditions significantly contributed to his death. No systemic medical errors were identified in his psychiatric care. Key lessons: workplaces must implement fatigue management systems, monitor staff wellbeing proactively, recognise moral injury in values-based work, and ensure adequate staffing levels to prevent burnout in employees with mental health vulnerabilities.