Inquest into the death of N
Deceased
N
Demographics
69y, female
Date of death
2012-04-16
Finding date
2015-07-02
Cause of death
Asphyxiation consistent with hanging
AI-generated summary
A 69-year-old woman admitted to Hornsby Hospital with seizures and subacute encephalopathy developed rapidly fluctuating mental state including anxiety, depression, suicidal ideation, and cognitive impairment. While individual investigations were appropriate, two critical failures occurred: (1) Dr A. did not recognize the patient's highly changeable mood as a major suicide risk factor and made no documented plan for ongoing psychiatric supervision or review—instead making assumptions about staff oversight; (2) an Individual Patient Special (one-to-one nursing) was implemented but removed after <24 hours without proper documentation, review process, or replacement with alternative supervision. The patient died by suicide seven days after admission while on a general medical ward. The coroner found the level of supervision was manifestly inadequate and emphasized need for integrated management of medically ill patients with psychiatric presentations in hospital settings.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Procedures
Contributing factors
- Failure to recognize highly changeable mental state as critical suicide risk factor
- Inadequate ongoing psychiatric supervision and care planning
- Premature removal of Individual Patient Special (one-to-one nursing) without appropriate replacement
- Lack of documented plan for psychiatric review while awaiting psychiatric unit transfer
- No daily psychiatric registrar review despite recommendation for transfer to psychiatric unit
- Assumption-based approach to care rather than explicit documented plans
- Mismatch between general medical ward supervision standards and psychiatric patient needs
- Inconsistent and under-resourced supervision titration available in medical ward
Coroner's recommendations
- Implementation of training for non-mental health workforce in suicide risk assessment and management protocols
- Development of integrated management protocols for medically ill patients with psychiatric presentations in general hospital wards
- Explicit documented plans from Consultant Psychiatrists including guidance to nursing staff on observation levels and safety measures when recommending transfer to psychiatric units
- Daily psychiatric registrar review of patients awaiting psychiatric unit transfer
- Strict adherence to Individual Patient Special policies including documentation of commencement, cessation, and daily review
- In-service training on suicide risk assessment and management protocols at Hornsby Hospital
- Development of intermediate supervision standards between one-to-one care and routine three-times-daily observations for high-risk patients in medical wards
Full text
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