Inquest into the death of AB
Deceased
AB
Demographics
27y, female
Date of death
2015-06-03
Finding date
2017-08-07
Cause of death
hanging, self-inflicted with intention of taking own life
AI-generated summary
A 27-year-old Aboriginal woman with borderline personality disorder died by suicide within hours of discharge from an emergency department. She presented after her GP attempted to schedule her under the Mental Health Act due to expressed suicidal thoughts with a specific plan (hanging). The emergency physician assessed her, found no acute suicide risk, and discharged her with no safety plan, no family notification, and no referral to the mental health consultation service available 24/7. Critical failures included: no referral to mental health specialists despite clear policy requirements; no consultation with family despite their presence; no written discharge plan; discharge by a non-authorised medical officer; and no documentation of the decision. The GP's use of an incorrect statutory form, while concerning procedurally, reflected genuine protective intent. The hospital's failure to follow its own policies regarding assessment, family involvement, and discharge planning directly contributed to a preventable death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- failure to refer to MHECS for comprehensive mental health assessment despite policy requirement
- failure to contact family members or support persons at discharge
- no written discharge management plan provided
- discharge assessment conducted without specialist mental health input
- discharge by non-authorised medical officer
- limited assessment duration and consideration of patient history
- use of safety contracting without proper clinical foundation
- no follow-up appointments arranged
- discharge late at night without adequate planning
- poor documentation of clinical decision-making
- discrepancy between hospital policy and actual practice
Coroner's recommendations
- Policies and procedures relating to persons presenting at the Emergency Department with a risk of suicide must be reviewed to require: (i) referral to MHECS for comprehensive mental health assessment for any person with any risk of suicide or presenting under the Mental Health Act; (ii) formulation and documentation of discharge management plans prior to discharge; (iii) written discharge management plans provided to patient at time of discharge regardless of MHECS involvement; (iv) procedures ensuring appointments required by discharge plans are made and appropriate follow-up occurs; (v) requirement to ask any patient being discharged whether a support person can be contacted on their behalf; (vi) clear direction on who is responsible for undertaking required steps and ensuring all steps are completed prior to discharge.
- All emergency department staff must receive training and support to understand applicable policies and ensure they are implemented.
- Emergency Department should have its own simple, clear policy specific to mental health presentations, avoiding ambiguity in interpretation.
- Establish clear delineation of ultimate responsibility to ensure discharge processes have been followed.
- Develop plain language policies to reflect mandatory referral to MHECS for any patient presenting with risk of suicide.
- Ensure discharge policy includes requirement to attempt to arrange family or support at time of discharge.
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