Inquest into the death of O A

44y · Male·multiple injuries from fall from cliff

A 44-year-old man with familial Mediterranean fever (FMF) and bipolar affective disorder with drug-induced psychosis died following a fall from a cliff at Vaucluse during a police rescue operation. He had been managing severe FMF pain with oxycodone, which he subsequently prescription-shopped from multiple doctors. Following detection of doctor shopping in March 2019, his access to Endone was restricted. He began self-medicating with cocaine in mid-2019, leading to admission with drug-induced psychosis in November 2019. After discharge, despite mental health support and anti-psychotic medication, his mental state deteriorated with increased paranoia, substance use, and suicidal ideation. On the night of death, police rescue officers engaged with him for over an hour on a cliff edge in poor weather; during a rescue attempt, he slipped from the officer's grip and fell. The coroner found the police response adequate and appropriate, hospital care adequate, and medical management of his pain reasonable given limited treatment options at the time. The death was determined to be misadventure rather than intentional.