Coroner's Finding: SIMMONETTE Sean Patrick

Contributing factors

• inadequate response to prior inhalant abuse incident on 20 January 1999
• failure to speak to patient about allegations
• failure to search patient rooms
• lack of enhanced supervision despite known risk
• incident not documented in client record
• poor communication between nursing and medical staff
• unsupervised smoking room not visible from nurses station
• access to fly spray from nurses station
• combination of paranoid schizophrenia, antisocial personality disorder, and polysubstance abuse

Coroner's recommendations

1. Nursing staff at James Nash House should be counselled about their failure to adequately respond to the alert in the Communication Book on 20 January 1999
2. The need for significant incidents being noted in the Client Record so that medical staff can be made aware should be reinforced
3. Security in Birdwood Ward should be reviewed, particularly so that if information is received that an item may be missing, an immediate inventory can be conducted to verify that allegation and further action can be taken
4. Consideration should be given to redesign of Birdwood Ward and Aldgate Ward to address visibility concerns, allowing staff to see patients whenever needed while maintaining appropriate privacy