Inquest into the death of CC
Deceased
CC
Demographics
33y, male
Date of death
2022-06-15
Finding date
2023-12-15
Cause of death
Hanging
AI-generated summary
CC, a 33-year-old First Nations man with methamphetamine-induced bipolar disorder and psychosis, was admitted to the High Dependency Unit at Nepean Hospital on 7 June 2022 under involuntary mental health detention. Over eight days, he received appropriate psychiatric care including antipsychotics, mood stabilisers and benzodiazepines at observation level 3 (30-minute observations). On 14 June, nursing staff discovered CC had torn a towel to make shoelaces; a second ripped towel was found on 15 June morning. These incidents, indicating potential self-harm risk, were documented on a handover board but not recorded in medical notes or communicated to treating doctors. At 2.20pm on 15 June, CC was found hanging in his ensuite bathroom using a ligature made from bedding. Despite prompt CPR, he died. The coroner found no criticism of clinical management. Key lessons: implement systematic flagging of significant clinical observations in electronic medical records so treating teams are alerted to potential risk indicators; eliminate functional ligature points from psychiatric ward doors as priority environmental safety measure.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- methamphetamine-induced bipolar disorder and psychosis
- failure to communicate ripped towel incidents to treating team
- significant clinical observations not documented in medical records
- functional ligature points available in psychiatric ward environment
- communication gaps between nursing staff and medical team regarding risk indicators
- patient's delusions and lack of insight into mental illness
Coroner's recommendations
- That Nepean and Blue Mountains Local Health District consider whether it would be appropriate to implement a process in the mental health ward, whereby nursing staff can highlight events they consider significant in the electronic medical record, with a view to drawing attention to such events for future nursing shifts and/or the treating team
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