Inquest into the death of Emma Jane Claridge
Deceased
Emma Jane Claridge
Demographics
19y, female
Date of death
2009-09-26
Finding date
2011-02-04
Cause of death
neck compression due to hanging
AI-generated summary
Emma Jane Claridge, 19, died by hanging at her home on 26 September 2009, nine hours after being granted day leave from the Cowdy Ward psychiatric ward where she was a voluntary patient. She had been admitted following acute suicidal ideation and received a diagnosis of hebephrenic schizophrenia. Although she expressed suicidal thoughts on 25 September, overnight leave was appropriately refused. On 26 September, after a review where she denied suicidal thoughts and could not formulate a safety plan, she was granted only day leave. The clinical team believed this was safe given her improvement and voluntary status. However, critically, there was lack of clarity about the scope and duration of leave between medical staff and family. The deceased was found with day leave materials and later took her own life. While clinical decision-making was defensible given fluctuating mental state and her previous successful leave experiences, system failures included inadequate handover communication, delayed escalation of her absence (5+ hours), and insufficient on-call mental health team involvement in the response.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- inadequate handover of clinical information between shifts
- lack of clarity regarding scope and duration of day leave granted
- delay in responding to patient absence from ward (5+ hours elapsed)
- insufficient involvement of mental health on-call team
- failure to ensure family understood the limitations of leave permission
- patient's inability to formulate safety plan for leave
- rapid escalation to schizophrenia diagnosis with poor prognosis
- medication side effects not adequately addressed before leave grant
Coroner's recommendations
- Ensure implementation of the Critical Incident Review recommendations undertaken by the Department of Health and Families regarding communication and handover procedures
- Implement enhanced formal handover procedures and note-taking systems to ensure continuity of care and inform subsequent clinical decisions
- Provide ongoing education to Cowdy Ward staff regarding correct procedures and policies for patient leave and AWOL management
- Ensure the Mental Health On Call Team is contacted when patients are absent without leave, in addition to police notification
- Complete and finalise the Protocol for Cooperative Arrangements in Mental Health Matters between the Commissioner of Police and Department of Health and Families
- Provide additional funding and resources to restructure the On Call Team into a 24-hour Critical Assessment Team as planned
- Ensure Government continues to adequately fund and resource mental health on-call teams to enable proper care for mentally ill patients
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