Inquest into the death of BQ
Deceased
BQ
Demographics
23y, female
Date of death
2021-07-18
Finding date
2025-09-29
Cause of death
hypoxic ischemic encephalopathy and aspiration pneumonia as a result of hanging
AI-generated summary
BQ was a 23-year-old Aboriginal woman who died by hanging on the Paringa Ward at Cumberland Hospital while detained as an involuntary mental health patient. She had a complex psychiatric history with schizophrenia and borderline personality disorder, substance use, and intellectual disability. Critical clinical lessons include: early access to comprehensive psychiatric history was delayed (6 days); risk assessment for suicide was inadequate despite signs of increased distress on the day of death; the Aboriginal Liaison Officer was unavailable due to COVID, compromising culturally appropriate care; her family was not informed of her arrest or hospitalization, which was inappropriate given her Aboriginal status and family importance; and observation practices were not contemporaneous or rigorous. While observation level was increased to 15-minute intervals, this was for absconsion risk rather than suicide risk. Better communication between hospitals, earlier comprehensive risk reassessment, and family notification aligned with cultural practices could have contributed to safer care.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- inadequate suicide risk assessment despite multiple signs of distress on day of death
- delayed access to prior psychiatric history from Shellharbour Hospital
- absence of Aboriginal Liaison Officer due to COVID-19 restrictions
- lack of culturally informed care plan
- failure to contact family despite knowledge of Aboriginal status and family importance
- inadequate documentation of treatment plan
- non-contemporaneous observation documentation
- patient had access to scarf used as ligature
- premature discharge from Shellharbour Hospital without secure accommodation
- NDIS funding delay creating homelessness risk
- placement with unvetted 'uncle and aunt' after discharge
Coroner's recommendations
- The Chief Executive Officer of the NSW Trustee and Guardian should make arrangements to provide First Nations cultural competency training to all NSW Trustee and Guardian staff with priority to those working with Aboriginal and Torres Strait Islander clients, and consider periodically repeating such training
- A copy of the Court's findings into the inquest into the death of BQ be referred to the New South Wales Attorney General
Full text
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