Coroner's Finding: DOBRIJEVIC Sofija
Deceased
Sofija Dobrijevic
Demographics
73y, female
Date of death
2007-08-16
Finding date
2010-05-07
Cause of death
neck compression by ligature
AI-generated summary
Sofija Dobrijevic, a 73-year-old woman detained under the Mental Health Act, died by ligature strangulation in a closed psychiatric ward at Glenside Hospital. She had chronic pain since a 2002 fall, depression, and histrionic personality disorder. Two days before her death, she told her son she would be 'found dead tomorrow' and he would 'be planning her funeral,' but this critical information was not effectively communicated to treating psychiatrists due to communication breakdown between her son, a junior medical officer unfamiliar with psychiatry, and the psychiatric registrar. The clinical team assessed her as moderate risk of self-harm without access to this information. Despite her longstanding suicidal ideation history, risk assessment protocols focused on acute vocalised intent rather than her longitudinal mental health history. Had the family's concerns been properly escalated to the psychiatrist, intensive observation and high-risk management strategies would likely have prevented her death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- failure to communicate critical information from family member to treating psychiatrist
- communication breakdown between non-psychiatric junior medical officer and psychiatric registrar
- risk assessment focused on acute vocalised suicidal ideation rather than longitudinal history of depression and suicidal ideation
- hourly observation frequency deemed adequate despite patient's known risk of self-harm
- no access to items or restraints that might have prevented self-harm
- patient's statements about funeral and death not properly escalated to senior psychiatric staff
Coroner's recommendations
- The Department of Health should continue to develop and implement risk management strategies that, in assessing risk of self-harm, take into account the patient's entire mental health history as known at the time of assessment.
- The Chief Executive Officer of the Department of Health should instruct clinical staff employed in acute and chronic mental health facilities that concerns expressed by members of a patient's family or by a patient's associates should be communicated to and properly evaluated by the patient's treating psychiatrist or psychiatric registrar.
Full text
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