Finding into death of William Andrew Poskitt

31y · Male·Injuries sustained in a fall from height

William Poskitt, a 31-year-old man with recently diagnosed HIV and Pneumocystis carinii pneumonia, died by suicide during a 4-day hospital admission. Despite requesting psychiatric assessment three times and displaying clear signs of psychological distress (racing thoughts, insomnia, dark thoughts, bizarre behaviour, anxiety), he did not receive a formal mental state assessment. The treating team referred him to HIV Psychiatry Liaison on day 1, but when he declined assessment on day 3 due to tiredness, no alternative arrangements were made despite his continued requests and family concerns. Prednisolone (40mg BD) likely contributed to his mental state changes. The coroner found the hospital missed multiple opportunities to implement preventative measures through failure to proactively follow up the psychiatric referral, poor communication between teams, and inadequate assessment of suicide risk. Clinical lessons include: always complete mental state assessments regardless of initial refusal; ensure clear accountability pathways for specialist referrals; monitor steroid side effects closely; and train staff in suicide risk assessment.