Record of Investigation into Death (Without Inquest)

Coroners Act 1995
Coroners Rules 2006
Rule 11

I, Robert Pearce, Coroner, having investigated a death of

Mr K

Find That : 

(a)        Mr K died on 23 May 2010 at Somerset Caravan Park; 

(b)        Mr K was born in Warburton on 14 December 1963; 

(c)        Mr K was in a de-facto relationship at the date of his death; 

(d)        Mr K died as a result of hanging. 

Circumstances : 

Mr  K was a 47 year old man originally from Victoria.  He had a long history of mental health problems with a diagnosis of paranoid schizophrenia.  He came to Tasmania in September 2009.  He received treatment from Tasmanian Mental Health Services including an admission to the Spencer Clinic Inpatient Unit from 25 September to 6 October 2009. 

On Sunday 23 May 2010 Mr K was discovered at about 5.10 pm in the caravan in which he lived at the Somerset Caravan Park hanging by a ligature around his neck.  He was dead.  A post mortem examination was conducted which concluded that the cause of death was hanging.  The circumstances leading up to his death and the evidence of how he was found establish to my satisfaction that Mr K took his own life.

Comments & Recommendations : 

The issues that arise from Mr K’s death follow from the circumstances in which he was discharged from the Spencer Clinic on the day of his death.  He had been taken to the emergency department of the North West Regional Hospital the day before, Saturday 22 May 2010.  The police had found him in a distressed state threatening self harm.  Mr K was assessed in the emergency department by a psychiatric registrar who discussed his condition by phone with a locum consultant psychiatrist.  Although when he was admitted he was suffering from auditory hallucinations and making continuing threats of self harm his condition the following morning, when he was assessed by the consultant psychiatrist, seemed improved.  He was discharged at 12.30 pm with an appointment to see a doctor the following day and to be seen later that day by the mental health crisis assessment and treatment team from the Department of Health and Human Services.  It was two nurses from the crisis team that found him in his caravan later that same afternoon. 

The investigation suggests that there may have been an insufficient clinical assessment, particularly given his history and presentation, of alternative treatment plans and the risk of discharging Mr K home alone.  This and other cases led to a review and improvement of policy and procedures for intake, admission and discharge of mental health patients in the north west of Tasmania.  I would add however that I am satisfied that Mr K’s engagement with services and compliance with treatment was poor.  He was a challenging patient and his death by suicide may have occurred even with improved practice.  The case highlights the difficulties faced by mental health professionals in caring for and assessing their patients. 

I have decided not to hold an inquest because the investigation has sufficiently disclosed the identity of the deceased person, the time, place, cause of death, relevant circumstances concerning the death and the particulars needed to register the death under the Births, Deaths and Marriages Registration Act.  I do not consider that the holding of an inquest would elicit any information further to that disclosed by the enquiries conducted. 

I see no need to make any formal recommendation.

DATED      11 October 2011 at Launceston in Tasmania


Robert Pearce