Hitchins, Steven John; Gudge, Shawn Bradley Joseph

Contributing factors

• Failure to conduct documented 15-minute observations (Hitchins)
• Access to plastic bags in common areas of mental health unit (Hitchins)
• Non-anti-ligature bedroom doorway design (Gudge)
• Standard hospital bed sheets accessible to patients (Gudge)
• Lack of systematic statewide environmental hazard management system
• Delayed implementation of previous coronial recommendations
• Inadequate statewide guidelines for ligature risk assessment
• Poor dissemination of lessons learned across hospital services
• Inadequate access to MET team due to security card issues (Gudge)
• Lack of anti-ligature modifications in high-risk areas

Coroner's recommendations

1. Queensland Mental Health should centralise within the State a body, with oversight from the Office of Chief Psychiatrist, tasked with reviewing and reporting to Hospital and Health Services on lessons learnt and opportunities for improvement through internal and external investigations (including RCA reports, Health Service Investigation Reports, Health Ombudsman Reports, and Coronial findings) as well as like reports from other States
2. The Office of the Chief Psychiatrist should commission an independent, external audit and review of the extent to which each relevant Hospital and Health Service has implemented the Ligature and Environmental Guidelines as well as the effectiveness of that implementation, with results shared with each Hospital and Health Service and opportunities for improvement identified