Deceased
Xysz Yiyujaa Tacdliwaazy
Demographics
22y, unknown
Date of death
2022-01-31
Finding date
2024-04-05
Cause of death
sudden death associated with volatile substance inhalation (butane and propane)
AI-generated summary
A 22-year-old Yolngu person with a well-documented history of volatile substance abuse (VSA) and mental illness was involuntarily admitted to Royal Darwin Hospital for acute psychosis. Due to COVID-19 bed-block, they were placed as an 'outlier' on a general ward rather than a mental health ward despite their acute presentation. Critical system failures contributed to their death from sudden inhalation of deodorant: the VSA risk was not clearly documented in the management plan; security staff and general ward nurses were not informed of the VSA or self-harm risks; the management plan was incomplete; there was no standardised handover procedure; and volatile substance products were freely accessible from hospital pharmacies. General ward nursing staff had received no mental health training. The Department of Health acknowledged this death was preventable and attributed it to absent clear procedures for managing mental health patients in general wards.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
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