Coroner's Finding: HOLLONDS Andrew David
Deceased
Andrew David Hollonds
Demographics
37y, male
Date of death
2009-11-19
Finding date
2013-04-24
Cause of death
compression of the neck consistent with hanging
AI-generated summary
Andrew David Hollonds, a 37-year-old man with personality disorder, substance misuse, and recent psychosis, presented to hospital after a suicide attempt (temazepam overdose) following job loss. He explicitly threatened hanging to his father. Although detained under the Mental Health Act with documented suicide risk, he was permitted unaccompanied cigarette breaks and subsequently absconded from the Emergency Department. Police located him hanging in his backyard within an hour. Key clinical failures included: inadequate supervision of a detained high-risk patient, permitting unsupervised departures despite explicit suicide threat, and ambiguous protocols regarding Code Black escalation and missing patient procedures. The coroner identified policy gaps around managing detained smokers and recommended clearer guidance on supervision requirements and consideration of alternatives such as nicotine replacement or secure outdoor areas.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- inadequate supervision of detained patient
- patient permitted unescorted cigarette break despite explicit suicide threat
- subsequent absconding from Emergency Department
- ambiguous Code Black policy not addressing calm departure scenario
- tension between Code Black policy and clinical practice manual abscond protocol
- lack of security office notification
- situational crisis following job loss
- personality disorder with impulsive and self-harm traits
Coroner's recommendations
- Minister for Mental Health and Substance Abuse to review existing practices and policies relating to smoking and detained mental health patients to provide clearest possible guidance to staff about when patients are to be accompanied and when they are not when absent from secure premises for a cigarette break
- Consider provision of nicotine patches as alternative to cigarette breaks
- Consider development of enclosed recreational outdoor courtyard areas connected to ward exits as secure areas allowing unaccompanied access
Full text
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