Inquest into the death of CCW
Demographics
68y, female
Date of death
2015-06-03
Finding date
2017-07-11
Cause of death
Hypoxic Ischaemic Encephalopathy as a result of Hanging
AI-generated summary
A 68-year-old woman with longstanding psychotic illness presented to ED with acute relapse, homicidal ideation toward her husband, and vague suicidal threats. Psychiatry assessed suicide risk as low based on her denial of self-harm intent and preoccupation with delusions about her husband. She was admitted to an acute psychiatric unit but placed in an open ward (rather than the planned observation area) due to bed unavailability. No escalation or consultation with the supervising consultant occurred regarding this change in plan. She died by hanging in her single room during night hours. Expert review found the initial assessment appropriate and suicide risk assessment reasonable, though one expert believed higher vigilance was warranted. The coroner found no criticism of the treating doctors, but noted that anti-ligature hardware was subsequently installed across mental health units.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Acute exacerbation of psychotic illness
- Non-adherence with antipsychotic medication
- Placement in open ward rather than observation area due to bed unavailability
- Lack of consultation with supervising consultant regarding change in care plan
- Inadequate assessment of suicide risk despite vague suicidal threats
- Insufficient ligature prevention measures in patient rooms
Coroner's recommendations
- Forward findings to the Minister for Health for consideration of 'back-to-base pulse oximetry' technology—wireless real-time monitoring devices measuring blood oxygen saturation that could alert nursing staff to rapid changes and prompt life-saving responses
- Review and strengthen mental health unit policies on observation levels and ligature prevention measures
- Implement anti-ligature door hardware in patient access areas (subsequently completed by SWSLHD)
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