Deceased
Ross Matthew Alcock
Demographics
22y, male
Date of death
2014-02-23
Finding date
2016-11-17
Cause of death
aspiration pneumonia complicating resuscitation for cardiac arrest due to neck compression due to hanging
AI-generated summary
A 22-year-old male with acute psychosis was admitted to a mental health ward under a Level 1 treatment order. Despite half-hourly observations, he hung himself using an electrical cord in his wardrobe. The ward layout had critical safety deficiencies: wardrobes created blind spots obscuring one bed from the doorway, the wardrobe served as a ligature point, and loose electrical cords were accessible. These hazards had been identified in previous safety audits but remained unaddressed. A nurse responsible for observations had poor understanding of his individual accountability for checks. While psychiatric assessment and treatment were appropriate, the preventable death occurred due to systemic failures in ward design and safety management rather than clinical misjudgement. The coroner found the death could have been prevented with proper ligature removal and room redesign.
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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