Deceased
Paul Laurie Mitton
Demographics
32y, male
Date of death
2009-01-19
Finding date
2012-10-26
Cause of death
hanging
AI-generated summary
A 32-year-old man with bipolar disorder and recent suicide attempt died by hanging in a closed psychiatric ward. He was admitted following overdose and suicidal ideation, deemed high-risk, and placed on standard half-hourly observations. Critical admission documentation (risk assessment and nursing assessment) was not completed despite adequate staffing. Staff failed to recognize ongoing suicide risk despite clear clinical indicators including expressed disappointment that overdose failed and statements of being unhappy to live. The coroner found the death preventable, noting that subsequent policy changes implementing 15-minute observations and environmental modifications acknowledge inadequate supervision. Key lessons: complete risk assessments on admission to high-acuity psychiatric units, escalate observation levels when documentation indicates high suicide risk, and ensure handover information translates to appropriate clinical precautions.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
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