Finding into death of Paul Peterson

54y · Male·Neck compression (hanging)

Paul Peterson, 54, died by hanging after leaving a private psychiatric hospital on unapproved leave while on close observations. He was admitted with major depression, suicidal ideation, and opioid dependence. On 1 July 2014, despite being on hourly observations and deteriorating mental state that evening (agitation, tremors after ceasing medication for ECT), he was allowed accompanied leave with his partner. The hospital's therapeutic leave policy was unclear and incompletely followed. Dr W. was unfamiliar with written procedures. Critically, leave was not formally approved that day despite policy requirements for pre-leave risk assessment before each specific instance. The patient's clinical deterioration that evening—evident agitation and tremors—should have triggered refusal of leave. No formal handover to nursing staff occurred on return. Systemic failures included lack of familiarity with policies, unclear written procedures, reliance on undocumented practices, and failure to recognise and act on acute clinical deterioration as a contraindication to leave.