Eady, Graeme William Julian
Deceased
Graeme William Julian Eady
Demographics
25y, male
Date of death
2003-10-19
Finding date
2007-06-20
Cause of death
hypoxic-ischaemic brain injury due to plastic bag asphyxia
AI-generated summary
Graeme Eady, 25 years old with chronic depression first formally treated in July 2003, was admitted after a suicide attempt in September 2003. Following an altercation with another patient, he was transferred to H Floor on 11 October 2003, where he was placed under a 15-minute observation protocol following an involuntary treatment order. On 15 October, he was found with a plastic bag over his head in the bathroom and could not be resuscitated. Clinical lessons include: the observation system relied on staff noticing missed rounds rather than fail-safe mechanisms; the 2.15 pm observations were not conducted, though the unobserved interval was approximately 20 minutes and did not materially affect outcomes; plastic bags cannot be eliminated from psychiatric units; and the identity of clinicians making ward transfer decisions should be documented. The treating team appropriately assessed suicide risk through monitoring, medication, involuntary treatment order, and frequent observations. This death highlights the importance of robust observation systems and clear documentation of clinical decisions.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- major depressive disorder with suicidal ideation
- breakdown in intermittent visual observation system (2.15 pm observations missed)
- reliance on ad hoc handover of observation duties rather than fail-safe system
- patient distress following ward transfer and perceived rejection
- difficulty establishing therapeutic alliance with ward staff
- patient anger and poor frustration tolerance
Coroner's recommendations
- Queensland Health should consider introduction of State-wide guidelines regarding intermittent visual observations of patients in mental health facilities
- Guidelines should establish clear written procedures directing: (1) the manner in which observations are to be performed; (2) the nurse or nurses responsible for carrying out observations; and (3) how observations are to be documented and recorded
- State-wide guidelines should be developed and implemented throughout Queensland in-patient psychiatric facilities to increase uniformity of observation practice and compliance
- Compliance with observation policy and procedures should be audited regularly
- The Queensland Director of Mental Health should investigate suitability of observation procedures similar to those adopted by the Royal Brisbane and Women's Hospital throughout Queensland
- Hospital records should clearly document the identity of the person making decisions to transfer patients between wards, as well as the clinical reasons for the transfer
Full text
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