Finding into death of N A

59y · Male·compression of the neck secondary to hanging

A 59-year-old man with treatment-resistant depression, anxiety, and suicidal ideation died by hanging while on weekend leave from psychiatric care. He had been hospitalised four times in 2021 and was receiving electroconvulsive therapy. On discharge morning, he disclosed suicidal thoughts to his psychiatrist but was offered weekend leave as an alternative to full discharge. Clinical staff attempted but failed to contact his wife to inform her of the discharge plan and recent suicidal ideation. While on leave, his mood deteriorated but he denied suicidal intent during a Monday morning review. He died by suicide later that day. The coroner found the psychiatrist's decision to allow leave was reasonable given available information, though communication with his wife—a key protective factor—was suboptimal. The coroner noted this communication failure was unlikely to have prevented his death but represented a missed opportunity for a more comprehensive assessment of his mental state.