Coroner's Finding: COPPING Leslie Walter

Contributing factors

• failure to communicate coronial recommendations from previous similar deaths to country hospitals
• inadequate risk assessment by nursing staff
• lack of communication between medical and nursing staff regarding patient confusion and fall risk
• windows not modified to prevent egress despite prior coronial findings
• patient's severe confusion and disorientation
• poor vision and hearing
• absence of notification system for coronial findings to country hospitals

Coroner's recommendations

1. The Minister for Human Services should consider how communication of coronial recommendations to country hospitals and health units might be improved
2. A safety audit should be carried out on all country hospitals to ensure that remedial action of the type undertaken at Naracoorte Hospital (window modifications) is undertaken at all such hospitals
3. The management of all such hospitals should consider how the assessment of patients who may be at risk of self-harm (whether through suicidal intent or simply because of confusion or other disability) can be made on the best possible basis, involving input from both medical and nursing staff in relation to each patient