Finding into death of David Mathew Smith

32y · Male·plastic bag asphyxia

David Mathew Smith, 32, died by plastic bag asphyxia on 25 November 2007. He had schizophrenia, chronic motor tic disorder, sexual paraphilia, and a history of explosive-making offences. He was subject to concurrent bail conditions and a Community Treatment Order requiring depot risperidone injections and forensic counselling. Smith rejected his mental illness diagnosis, refused antipsychotic medication, and experienced clinical depression in September 2007. Following an attempted suicide on 2 September, he was admitted involuntarily. On 22 November, his psychiatrist refused his plea to revert to oral medication, instead offering a conditional compromise that required attendance at clinic. Smith told his mother he preferred death to continued injections. He avoided three weeks of injections, then died four days after receiving his last dose. The coroner found that the dichotomy between concurrent criminal justice and mental health orders, combined with rigorous enforcement of medication compliance despite absent psychotic symptoms post-discharge, inappropriately pressured Smith and contributed materially to his suicide. The treating team, influenced by concerns about his sexual re-offending risk, imposed involuntary depot medication without evidence of ongoing psychosis or demonstrated connection between antipsychotics and his paraphilic behaviour.