Sidi Chax Bojang · Prevention of Future Deaths report

On the 22nd July 2024 I commenced an investigation into the death of Sidi Chax Bojang, aged 34. The investigation concluded at the end of the inquest on the 22nd July 2025. The conclusion of the inquest was Consequences of an untreated mental health condition. The medical cause of death was 1a Multiple Injuries.

On the 19th July 2024 at about 16.41 Sidi Chax Bojang left the platform at Oakleigh Park Railway Station and was struck by a fast train passing through the station.

Mr Bojang was clearly unwell and had attended the Accident and Emergency department the day before complaining of a “wooshing” sound and seeing flashes of light when he was triaged. He had attended with feelings of self harm and had reported an attempt to cut his wrist and stab himself ████████
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Mr Bojang had sought help from the hospital but after assessing him and, as he said he felt better and agreed to see his GP, was allowed to leave.

It is likely that Mr Bojang was seriously ill, and may have had auditory and visual hallucinations and this was not recognised when he was examined.

The symptoms may have been incorrectly attributed to his use of cocaine taken the week before and drinking beer and whiskey 2-3 times a week.

On the day he died Mr Bojang called an ambulance at 04.53 in the morning saying he had cut himself ████████ and was taken to the A&E Department at 07.30 but had left the hospital by the time the psychiatric liaison team had arrived.

Where there is a significant change in presentation when assessed suggesting that the patient is now well, when either the same day, or a short time before presentation, acts of self harm, suicidal behaviour or thoughts were present.

That a psychiatrist did not review the person presenting before discharge.

The discharge of the person in these circumstances fell to a senior psychiatric nurse.