Inquest into the deaths of LF, Merryn Ward and Shao
Deceased
LF
Demographics
33y, female
Date of death
2019-09-02
Finding date
2026-06-30
Cause of death
Hanging
AI-generated summary
A 33-year-old woman with major depressive disorder died by hanging while voluntarily admitted to a mental health inpatient unit. She was stabilizing on medication and scheduled for transfer to a private facility. The coroner found reasonable and appropriate care was provided, though noted the ligature was likely craft material she had been using therapeutically. The death highlighted the clinical tension between providing therapeutic amenities and restricting access to potential ligatures. Craft materials were subsequently removed from the ward. The case underscores challenges in suicide prevention in inpatient settings and the importance of balancing patients' autonomy with safety.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Clinical conditions
Contributing factors
- Access to craft materials used as ligature
- Change of status to voluntary admission
- Family visit causing distress
- Delayed response to husband's concerns about patient statements
Coroner's recommendations
- Review and update serious incident management policy to provide guidance on preserving evidence following self-harm incidents, including locating and preserving items used in the incident and identifying staff with knowledge of the incident
Full text
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