Deceased
Daniel Peter Scoleri
Demographics
31y, male
Date of death
2014-07-24
Finding date
2017-05-11
Cause of death
acute neck compression due to hanging
AI-generated summary
A 31-year-old man with depression, substance use history, and prior suicide attempts presented to the Emergency Department after a motor vehicle accident on 23 July 2014. He expressed suicidal ideation and was appropriately detained under section 56 of the Mental Health Act 2009 for psychiatric assessment. An emergency physician (Dr H.) and her supervised intern made a reasonable clinical decision not to assign a patient minding guard, based on information available to them. However, an agency mental health nurse (Ms Clarke) subsequently assessed him as low risk and permitted him to leave for breakfast at approximately 5:45am without notifying other staff or implementing the detention requirement. The patient died by hanging later that day. The coroner found Ms Clarke's decision to release a detained patient was unpredictable, perverse, and could not have been foreseen by other responsible staff. No systemic failures or clinical errors by the supervising physician were identified.
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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