Deceased
JP
Demographics
46y, female
Coroner
Decision ofDeputy State Coroner Ryan
Date of death
2017-10-19
Finding date
2020-11-27
Cause of death
hypoxic brain injury due to hanging
AI-generated summary
A 46-year-old woman with borderline and antisocial personality disorder, depression, and cannabis dependence died by suicide while an involuntary psychiatric inpatient. She had previously expressed suicidal ideation including specific plans to hang herself. Key failures included: inadequate pre-discharge psychiatric review (required within 24-48 hours of discharge but not performed); premature communication to the patient about discharge into custody without psychiatric assessment or support; no discussion of her identified severe anxiety about returning to prison; a hiatus in nursing observations during the critical period; and failure to remove a garment she had twice attempted to use as a ligature. The coroner found staff interactions suboptimal and clinical implementation of transfer-of-care policy deficient, though acknowledged no formal discharge decision had been made.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
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39y · Male·Hanging
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Male·Gunshot wounds to the head
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