Inquest into the Death of Peter James WILSON

41y · Male·complications in association with effects of fire, with terminal palliative care

Peter James Wilson, 41-year-old male with complex mental health history including bipolar affective disorder, anxiety, OCD, and possible schizophrenia, died by suicide on 1 November 2021 after self-immolating with boat fuel while on a Community Treatment Order. Wilson was discharged from Graylands Hospital on 29 October 2021 following a 12-day admission for management of psychosis and recent suicidal behaviour (drain cleaner ingestion). Key deficiencies included: failure of discharging psychiatrist to discuss CTO directly with receiving community psychiatrist; non-provision of discharge summary to community service; absence of written information about diagnosis, new paliperidone depot injection, and potential medication side effects; and lack of weekend follow-up despite Friday discharge. While Wilson's mental state appeared stable at discharge and suicide risk was assessed as low, his parents later reported concerning medication side effects including tremors and breathing difficulty. The coroner found the discharge plan compromised but could not conclude that communication failures were causative of death, given the unpredictability of suicide and absence of documented acute warning signs.