Coronial
NSWmental health

Inquest into the death of R R

Demographics

38y, female

Coroner

Decision ofDeputy State Coroner Grahame

Date of death

2015-04-21

Finding date

2018-12-19

Cause of death

neck compression (hanging)

AI-generated summary

RR, a 38-year-old woman with complex mental health history including PTSD, substance use disorder, and borderline personality traits, was admitted to Bloomfield Hospital on 12 April 2015 following an overdose with stated intent to hang herself. Critical gaps in her care included: failure to communicate critical information about a discovered noose and suicide notes at her home to the treating psychiatrist; inadequate formal documentation of suicide risk assessments; reclassification to voluntary status and care level 4 (2-hourly observations) on 15 April without documented consideration of the new housing information; no psychiatric review in the final 6 days before her death; and confusion about actual observation frequency (staff retrospectively marked observations). RR hanged herself on 21 April 2015. Key clinical lessons: critical safety information must be actively communicated to senior clinicians; suicide risk assessments require structured, documented formulation; observation frequency should align with actual care level and risk; and regular psychiatric review intervals should be maintained even when patients appear improved.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

psychiatryemergency medicinepsychologygynaecology

Error types

communicationsystemdelaydiagnostic

Clinical conditions

major depressive disorderpost-traumatic stress disordersubstance use disorderborderline personality disordersuicidal ideation

Contributing factors

  • failure to communicate critical safety information (discovered noose and suicide notes) to treating psychiatrist
  • inadequate documentation of suicide risk assessment by treating psychiatrist
  • reclassification to voluntary status and reduced care level without documented safety review
  • no psychiatric review in final 6 days before death
  • confusion about observation frequency - documented as 30-minute intervals but not reliably performed
  • observations retrospectively marked by nursing staff when missed
  • unescorted ground leave continued despite high-risk history
  • inadequate specific risk management plan documented
  • poor flow of information between departments and staff

Coroner's recommendations

  1. WNSWLHD give consideration to extending the prohibited items list in the Adult Acute Unit to include ligatures, in line with the restrictions currently in place in the Mental Health Intensive Care Unit (MHICU)
  2. WNSWLHD give full consideration to the results of the Back to Base Oximetry Trial currently being undertaken by the Black Dog Institute and Hunter New England Local Health District when they become available, with a view to assessing whether the technology would be useful at Bloomfield Hospital
Full text
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