Inquest into the death of RA

Contributing factors

• inadequate and inconsistent search procedures for ligature risks between low and high dependency units
• insufficient documentation of what items were removed and where they were stored
• failure to ensure systematic removal of potential ligatures from low dependency unit
• patient's fear of institutions related to childhood trauma at boarding school
• patient's resistance to involuntary admission
• rapid deterioration in mental health following medication changes
• recent suicide attempt 24 hours prior

Coroner's recommendations

1. Implementation of consistent search procedures across all low and high dependency units (now implemented)
2. Mandatory removal of all potential ligatures including shoelaces and clothing cords from all patients across all acute mental health units (now implemented)
3. Improved electronic documentation of patient searches including itemisation of what was removed and where items are stored (new template implemented)
4. Enhanced staff education regarding search procedures and prohibited items, including for casual, relief and agency staff (now implemented)
5. Environmental modifications to eliminate ligature points including removal of curtain rods, anti-ligature door hardware, and gaps at top and bottom of doors (implemented in new facility)
6. Regular audits of search compliance and observation practices (now implemented)
7. Twice yearly environmental safety audits to identify ligature risks (now implemented)
8. Therapeutic redesign of high dependency unit to reduce trauma and distress (new facility designed and to open May 2024)
9. Senior nursing staff available out of hours and weekends to manage critical incident communication with families
10. Review by NSW Health of policy regarding notification of police following serious suicide attempts that may result in death
11. Updated clinical procedure for assessment of suicide risk to ensure screening tools are not used in isolation and therapeutic relationship is considered