Coronial
VICmental health

Finding into death of Long Ngoc Dinh

Deceased

Long Ngoc Dinh

Demographics

28y, male

Coroner

Coroner John Olle

Date of death

2010-04-18

Finding date

2013-07-02

Cause of death

Drowning

AI-generated summary

Long Ngoc Dinh, a 28-year-old man with schizophrenia and obsessive-compulsive disorder, died by drowning in the Maribyrnong River after absconding from the Mental Health Rehabilitation Unit in Sunshine on 17 April 2010. He had been admitted for management of severe obsessive-compulsive symptoms and was case-managed with psychological support. He left the ward by pushing past staff around 9.30am and was found deceased face-down on rocks the following morning. Police were notified of his absence at 12.25pm. His sister contacted the unit after seeing him at 3pm, and staff believed the Community Care Unit would contact them if he attended. The autopsy confirmed drowning as the cause. Clinical lessons include the need for robust absconding protocols, immediate and comprehensive search procedures when vulnerable psychiatric inpatients go missing, clear communication between mental health services, and consideration of enhanced observation levels for patients with acute symptom exacerbation.

AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.

Specialties

psychiatryforensic medicine

Error types

systemcommunication

Contributing factors

  • Absconding from mental health facility
  • Schizophrenia and obsessive-compulsive disorder
  • Acute exacerbation of psychiatric symptoms
  • Inadequate absconding prevention measures
  • Communication gaps between mental health services
  • Delayed search procedures
Full text

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2010 1458

FINDING INTO DEATH WITH INQUEST

Form 37 Rule 60(1) Section 67 of the Coroners Act 2008

Inquest into the Death of: LONG NGOC DINH Delivered On: 02 July 2013

Delivered At: Coroners Court of Victoria Level 11, 222 Exhibition Street, Melbourne 3000

Hearing Dates: 19 April 2013 Findings of: John Olle, Coroner

Police Coronial Support Unit Senior Constable Kelly Ramsey

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I, JOHN OLLE, Coroner having investigated the death of LONG NGOC DINH

AND having held an inquest in relation to this death on 19 April 2013 at MELBOURNE

find that the identity of the deceased was LONG NGOC DINH

and the death occurred on or about 18 April 2010

at Maribyrnong River, Footscray 3011

from:

l(a) CONSISTENT WITH DROWNING

in the following circumstances:

  1. Long Ngoc Dinh was aged 28 years at the time of his death. Mr Dinh was an inpatient at the Mental Health Rehabilitation Unit in Sunshine. He ordinarily resided at 21 Tudor Road, North

Sunshine.

2, The coronial brief has fully addressed the circumstances of Mr Dinh’s death,!

3. At inquest my assistant read the following summary into evidence:

“On Sunday the 18th of April 2010, at approximately 10.30am, the deceased, Long Ngoc Dinh (03/11/1981) was located lying face down on the rocks on the Western side of the Maribyrnong River approximately 20 metres south of the Dynon Road Bridge,

Footscray.

Mr Dinh had an extensive history of Schizophrenia and Obsessive Compulsive Disorder with his first admission to a mental health facility was at Orygen in 2003. At this time he

was diagnosed with Schizophrenia.

In September 2009, he was admitted to the Sunshine Acute Adult Psychiatric Unit within the Sunshine Hospital. Mr Dinh had been displaying aggressive and violent

behaviour towards his family.

' A copy of the brief will remain on the court file.

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He was later discharged back to the care of the Mobile Support and Treatment Team with a referral to the Adult Mental Health Rehabilitation Unit of the Mid West Area Mental Health Service.

At the Community Care Unit in St. Albans, Mr Dinh became unmanageable due to his aggression, violence, damage to property and assaulting staff. He was re-admitted to the Sunshine Acute Adult Psychiatric Unit and referred to the Adult Mental Health

Rehabilitation Unit in Sunshine.

Mr Dinh was transferred from the Sunshine Acute Adult Psychiatric Unit on the 24th of March 2010 for management of severe obsessive compulsive symptoms and responded

well. He was case managed and given psychological support.

Treating doctors reviewed Mr Dinh from admission on the 24th of March 2010 until he left the ward by pushing past staff while they were letting another client in to the unit.

This occurred at approximately 9.30am on the 17th of April 2010.

At 12.25pm, Mr Dinh was reported missing to the Keilor Downs Police by staff member Rhonda Piriez. A search of the area was undertaken by police members however they were unable to locate Mr Dinh. Further patrols were undertaken throughout the day with the hospital contacted for any update. Police Incident number 100109803.

At approximately 3.00pm on the 17th of April 2010, Mr Dinh visited his sister, Hang Dinh, at her children's clothing store in the Brimbank Shopping Centre. Mr Dinh asked his sister for $50.00. His sister gave him $10.00. Mr Dinh told his sister that he was living at the St. Albans Community Care Unit at 3/38 Evergreen Avenue in St. Albans.

Mr Dinh's sister advised staff at the Adult Mental Health Rehabilitation Unit that her brother had been to see her. Following this, staff from the AMHRU contacted the Community Care Unit and Keilor Downs Police station to update them on the situation.

Amanda Atkins from the AMHRU believed the Community Care Unit would contact them if Mr Dinh was to attend the Unit.

On the 18th of April 2010, at approximately 10.05am, Mr Dinh was located by a passing rower, Terry Blyth. Mr Dinh was located in the position as described earlier, face down

on the rocks. Mr Blyth then contacted police.

? T have reviewed the VicPol missing persons reports.

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At approximately 10.30am, police arrived at the scene and cordoned the area surrounding the deceased. The Footscray Criminal Investigation Unit was notified and

attended.”3 Post Mortem Medical Examination

  1. On 29 April 2010, Dr Sarah Parson, Forensic Pathologist at the Victorian Institute of Forensic Medicine performed an autopsy on the body of Long Ngoc Dinh.

5. Dr Parsons found the cause of death to be consistent with drowning.

6. Dr Parsons commented:

“Long Ngoc Dinh was a 28 year old man who according to the circumstances as detailed in the Victorian Police Report of Death, Form 83 was located deceased lying on the rocks on the western side of the Maribyrnong River under the Dynon Road bridge. The deceased was dressed in black track suit pants with white stripe down leg and black long sleeve top. The deceased did not have any identifying documents or ID on him when located or any marks, scars or visible tattoos. There were no signs of violence, trauma or injuries. The deceased was lying on stomach at low tide mark of river. There were no

vehicles, boats or fishing rods in the area. There were no signs of struggle or weapons,

The deceased has a significant psychiatric history at the Western/Sunshine Hospital

where he has a diagnosis of schizoaffective disorder and multiple admissions.

Scene photographs have been examined and show an Asian male facedown adjacent to a

rocky ledge with a high tide line above him.

_The cause of death in this 28 year old male is consistent with drowning. Some signs seen in classical drowning include a foam plume around the mouth (which can quickly disappear), heavy and over distended lungs, blood stained fluid within the airways and in

some cases, pleural effusions may be present. These were all present in this man.

Toxicological analysis on post mortem specimens has detected drugs consistent with

therapeutic usage.

} Summary inquest brief read into evidence.

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This case has been reviewed in it’s entirety by a second pathologist.

Finding

I find the cause of death of Long Ngoe Dinh to be consistent with drowning.

I direct that a copy of this finding be provided to the following:

Mrs Thi Nhung Vu Senior Constable Len Clark, Footscray Police Station, Investigating Member

Interested Parties

Signature:

JOHN OLLE CORONER Date: 2 July 2043

  • Comments section Autopsy Report.

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