Coronial
QLDmental health

Mrs B

Deceased

Mrs B

Demographics

52y, female

Date of death

2008-03-15

Finding date

2013-07-02

Cause of death

Hanging due to depression

AI-generated summary

Mrs B, a 52-year-old woman with a 17-year history of recurrent depression, suicidal ideation, and borderline personality traits, was admitted to Cairns Base Hospital Mental Health Unit on 11 March 2008 with escalating suicidal ideation and plans to hang herself. On 14 March, after Dr L. assessed her as not being at acute high risk of suicide and placed her on category B observations (15-minute checks), she absconded within minutes and purchased rope and a stepladder from a nearby hardware store. She was found hanging at the Cairns Showgrounds on 15 March. While the coroner found Dr L.'s clinical assessment and observation level were reasonable given the need to balance therapeutic care with safety, the case highlights the critical importance of physical monitoring of mental health unit exits. Her selective disclosure of symptoms to clinicians, her history of impulsive absconding when hospitalised, and recent acute suicidal ideation documented by nursing staff suggested higher risk than her presentation to the psychiatrist indicated.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

psychiatry

Error types

communicationsystem

Drugs involved

diazepamoxazepamtemazepamolanzapinequetiapineamilsulpridevenlafaxineescitalopram

Clinical conditions

recurrent major depressive disordertreatment-resistant depressionborderline personality disordersuicidal ideationauditory hallucinationsmixed affective statealcohol abuse

Contributing factors

  • Absconding from Mental Health Unit immediately after psychiatric assessment
  • Inadequate physical monitoring of the entrance to the Mental Health Unit
  • Possible discrepancy between patient presentation to nurse versus psychiatrist
  • Patient's capacity for selective disclosure of symptoms
  • Lack of inquiry into circumstances of earlier absconding on 12 March
  • Unresolved diagnostic uncertainty regarding primary condition (treatment-resistant depression versus borderline personality disorder)
  • Absence of medical records during psychiatric assessment

Coroner's recommendations

  1. Qld Health or the Director of Mental Health should investigate and develop a statewide policy about preferred options for managing and monitoring the risk of absconding, including through physical layout and staffing of reception-like facilities at the main entrance to Mental Health Units
  2. This policy should serve as a guide to the construction of new Mental Health Units and modification of existing units
  3. There is a need for consistent state-wide application of best practice regarding physical safeguards to prevent absconding, not left to individual facility managers to decide
Full text
Official source Archived copy

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Source and disclaimer

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