Coroner's Finding: CULO John

44y · Male·multiple injuries sustained when struck by a semi-trailer as a result of suicide

A 44-year-old man with chronic bipolar disorder and severe depression died by suicide while detained under the Mental Health Act at a psychiatric hospital. He was hit by a semi-trailer after absconding from an open ward. The coroner found his treatment was appropriate and that staff could not reasonably have prevented his departure. He was receiving mood stabilisers, antipsychotics, and anxiolytics, with close observation and suicide risk awareness. The decision to manage him in an open ward rather than closed was reasonable given his cooperation history, though notes suggested transfer to closed ward consideration if agitation persisted. The inquest concluded that care and management were appropriate and no preventative measures were omitted.