Inquest into the death of Trevor SAMUEL

35y · Male·hyponatraemia due to excessive consumption of water, against a background of psychogenic polydipsia and treatment resistant schizophrenia

Trevor Samuel, a 35-year-old Aboriginal and Torres Strait Islander man with treatment-resistant schizophrenia and psychogenic polydipsia, died in custody from hyponatraemia following excessive water consumption. His psychiatric care by Dr R. was judged adequate within prison constraints, with appropriate sodium monitoring, fluid restriction, and medication adjustments. However, expert witnesses unanimously agreed that serious mental illness requires treatment in forensic hospitals rather than prison hospitals. The prison model relies on restrictive confinement (23-hour cell isolation) which, while controlling water access, prevents therapeutic relationships and psychological recovery. Key clinical lessons: (1) psychogenic polydipsia requires intensive monitoring and can rapidly progress to life-threatening hyponatraemia; (2) treatment-resistant schizophrenia poses significant management challenges; (3) custodial environments prevent optimal psychiatric care despite staff competence; (4) Aboriginal overrepresentation in custody with mental illness requires targeted systemic reform.