On 12 May 2014, the Coroners Court of Victoria delivered its findings (without inquest) into the death of Mark Raymond Parsell, who committed suicide in 2008 shortly after leaving Dandenong Hospital's Emergency Department, where he was awaiting admission to the Psychiatric Ward.  The Coroner found that Mr Parsell’s death was caused by multiple injuries sustained when he was struck by a train.  However, the Coroner also noted several contributing factors relating to his mental illness and engagement with public mental health services.

Immediately before his death, Mr Parsell was assessed by medical staff as being at a medium risk of suicide, self-harm and absconding and at a high risk of non-compliance.  The Coroner held that, in light of Mr Parsell’s assessment, there was a lack of adequate clinical handover, a lack of supervision and an inadequate level of care.

The Coroner further commented that Mr Parsell presented in a manner (and with a history) that should have alerted staff to a need for close supervision and involuntary admission status, which would have triggered lawful detainment under the Mental Health Act 1986 (Vic).

To view the findings, click here