Deceased
Sandra June Sanders
Demographics
42y, female
Date of death
1997-09-03
Finding date
2000-04-07
Cause of death
salt water drowning
AI-generated summary
Sandra Sanders, aged 42, a detaineε psychiatric patient, died by saltwater drowning after absconding from Woodleigh House psychiatric unit on 3 September 1997. She had presented with major depression with psychotic features following a recent suicide attempt, and was appropriately detained under the Mental Health Act. The coroner identified critical failures in implementation of care: (1) Dr. Kent's request for 'close supervision' was not translated into action by nursing staff, (2) staff failed to detect two unnoticed absences (2 and 3 September), (3) grossly inadequate documentation from 2 September until after she disappeared, and (4) slow response (3+ hours before police notified at 3.50pm). Had the absences been detected, Dr. Kent stated she would have implemented one-to-one nursing or transfer to a closed ward. The coroner found significant lapses in nursing care quality and emphasized that detained patients require clearly specified observation protocols with proper documentation.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
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