Jeffrey, Helen

Contributing factors

• Transfer from PICU to general ward despite suicide risk
• Lack of staff awareness of plastic bag as suicide method
• Absence of documented observation logs
• Observation intervals exceeding medical direction (30 minutes vs 15 minutes prescribed)
• Supply of plastic bag to patient for benign purpose without recognition of hazard
• Unclear statutory requirements for treatment planning
• Inadequate nursing protocols for visual observations

Coroner's recommendations

1. Establish a committee to consider the suitability of discrete treatment plan documents versus progress notes under the Mental Health Act, and propose statutory amendments for clarity
2. Pending statutory changes, strongly emphasize to medical practitioners that a discrete treatment plan document should be completed
3. Introduce mandatory logging of all visual observations of patients in State mental health facilities with audit compliance mechanisms
4. Examine the practicability of introducing uniform nursing practices across State mental health facilities in essential areas of patient care
5. Issue protective face shields for CPR administration personally to all nurses, with technical information establishing effectiveness, and require carriage at all times
6. Exclude from State mental health facilities all objects commonly identified as means of suicide or attempted suicide, immediately inform nursing staff of these devices and their common use, and establish management practices for continuing audit
7. Refer the concept of a remote pulse-monitoring device to a suitable person or body to evaluate technological feasibility, nursing value, and economic practicability