Inquest into the disappearance and suspected death of Christine Joyce Dorothy Young
Deceased
Christine Joyce Dorothy Young
Demographics
40y, female
Date of death
2016-04-24
Finding date
2018-09-07
Cause of death
The medical cause of death was unable to be determined. Manner of death: unintentionally caused by misadventure – absconded from Mental Health Inpatient Unit while involuntarily detained and suffering from paranoid schizophrenia, walked into desert scrubland and was not located.
AI-generated summary
Christine Young, a 40-year-old Aboriginal woman with paranoid schizophrenia, absconded from a locked mental health inpatient unit and walked into desert scrubland where she died. Critical clinical lessons include: (1) failure to identify her during ED presentation on 21 April when she was found semi-naked at the airport – staff did not access her known psychiatric history despite police providing her name, missing a clear opportunity for admission; (2) inadequate psychiatric assessment that night – the ED doctor did not consult the on-call psychiatrist despite clear psychotic symptoms and paranoia; (3) insufficient observation and management on the unit – she was permitted unescorted leave while highly agitated despite no recent medication; (4) failure to anticipate absconding risk given her documented history of multiple previous absconding episodes; (5) system failures in the women's refuge where she was placed overnight without night staffing; (6) lack of Aboriginal Health Liaison Officer availability after hours, even though their presence significantly calmed her. Multiple preventable failures in communication, clinical assessment, and risk stratification contributed to this tragedy.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Failure to access known psychiatric history during ED presentation on 21 April despite police providing patient name
- Failure of ED doctor to consult on-call psychiatrist despite clear psychotic symptoms and paranoia
- Missed opportunity for admission on 21 April
- Inadequate assessment of absconding risk given documented history of multiple previous episodes
- Granting of unescorted leave while patient was highly agitated and recently admitted
- Poor supervision of unescorted leave with unclear monitoring protocols
- Inadequate physical security (lack of airlock door system allowing patient to exit when other patient was leaving)
- Lack of night staffing at women's refuge where patient was placed overnight
- Unavailability of Aboriginal Health Liaison Officer after hours despite their demonstrated clinical value
- Inadequate clinical handover to MHIPU staff regarding patient's history of absconding
Coroner's recommendations
- Funding be requested for an additional Aboriginal Health Liaison Officer to be rostered on weekends and on call overnight for Aboriginal mental health patients at Broken Hill Hospital
- Consideration be given to implementation of a system to ensure Aboriginal Mental Health Inpatients who do not have leave be granted personal access to an Aboriginal Mental Health Worker or Aboriginal Health Liaison Officer
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