Coroner's Finding: DOOMA Renato
Deceased
Renato Dooma
Demographics
36y, male
Date of death
2004-10-07
Finding date
2006-12-21
Cause of death
Multi-organ failure due to consequences of multiple injuries sustained following motor vehicle collision
AI-generated summary
A 36-year-old man with chronic treatment-refractory paranoid schizophrenia was involuntarily detained in an acute psychiatric ward after a failed community trial. Despite being a documented high absconding risk, he was transferred from the secure closed ward to an open ward to accommodate more acute patients. Within hours, after receiving PRN medication for agitation, he absconded unnoticed due to inadequate observation practices and was struck by a motor vehicle, sustaining multiple injuries including head trauma. He died 17 days later from multi-organ failure and sepsis. The coroner identified preventable factors: shortage of extended-care beds forcing retention in unsuitable acute facilities, failure to implement documented half-hourly observation protocols, and lack of additional supervision arrangements when moving a known absconding risk to an open ward. Systemic failures in mental health resource allocation and individual staff failures in patient observation contributed to this death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Shortage of extended-care beds at Glenside Hospital forced retention in unsuitable acute facility
- Rejection of application for extended-care bed by Glenside despite clinical need
- Transfer of high absconding-risk patient from closed to open ward to accommodate more acute patients
- Inadequate nursing observation of patient despite documented high absconding risk
- Failure to implement documented half-hourly observation policy
- Lack of additional supervision arrangements when moving known absconding risk to open ward
- Insufficient staffing and support to maintain required observation levels
- Long delay in detecting patient's absence from ward (over 4 hours)
Coroner's recommendations
- Provision be made to increase the number of closed ward extended care beds available at Glenside Hospital (or suitable alternative facility) for persons with chronic mental illness who have not responded sufficiently to treatment in acute facility and who are deemed unsuited to management in community
- Administrators and senior nurses in acute psychiatric facilities examine their observation policies and practices to ensure that patients who have been detained in these facilities and have not been granted leave in the community are adequately supervised
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —