Finding into death of Mr LY

42y · Male·Multiple injuries sustained in a fall from a height

Mr LY, a 42-year-old compulsory inpatient with extensive mental health history, died by suicide when he jumped from the Belford Road overpass during approved unescorted leave. Key clinical events included a concerning psychiatric review on 2 March 2017 where he made a conditional suicide threat (stating 'I'll just commit suicide' if injected), and a family meeting on 3 March 2017 where disputed statements about suicide may have been made. The coroner found that Associate Nurse Unit Manager Lucy Graham's approval of unescorted leave on 4 March 2017 was reasonably open to her on the basis that Mr LY appeared calm and presented without overt distress. The coroner noted the inherent unpredictability of suicide risk and the difficulty health professionals face in predicting when patients will act on suicidal ideation, emphasising that risk behaviour is often impulsive and prior risk factors can rapidly become outdated.