Inquest into the death of Chloe Jane Campbell

AI-generated summary

Chloe Jane Campbell, aged 32, died by suicide while an involuntary inpatient with borderline personality disorder, complex PTSD, and chronic suicidal ideation. She was admitted 18-30 April 2019 after ceasing medications and experiencing suicidal ideation. Care was clinically appropriate including risk assessments, observations, and medication use consistent with guidelines. She hanged herself using bedsheet over ensuite door on 29 April evening, suffering hypoxic brain injury and cardiac arrest; died 30 April. Coroner found treatment appropriate but noted systemic issues: ensuite doors represented known ligature risk (identified in 2015 and 2018 audits marked for 'local management') that were not addressed through capital works until after her death. Coroner found this consistent with statewide approach at the time, with environmental hazard management shifting toward built environment modifications only from 2018 onwards following prior coronial findings.

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