Coroner's Finding: NOONAN Ricky Dale
Deceased
Ricky Dale Noonan
Demographics
54y, male
Date of death
2015-09-27
Finding date
2020-09-22
Cause of death
Hypoxic-ischaemic brain injury attributed to cardiac arrest due to choking
AI-generated summary
A 54-year-old man with paranoid schizophrenia died of hypoxic-ischaemic brain injury from choking on food whilst in seclusion in a psychiatric intensive care unit. Key failures included: unsupervised provision of food to a patient with poor dentition and sedating medications increasing aspiration risk; inadequate continuous monitoring of the seclusion room by CCTV despite a monitor displaying real-time footage being immediately available to nursing staff; failure to communicate with the patient every 15 minutes as required; and haphazard observation documentation not reflecting actual practice. The CCTV footage showed the patient collapsed motionless for 11-12 minutes before detection. Earlier detection via continuous CCTV monitoring would likely have prevented death, and supervised feeding would have prevented the initial choking incident entirely. The new practice of continuous face-to-face observation outside seclusion rooms has since been implemented.
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Specialties
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- Unsupervised provision of food to patient in seclusion
- Inadequate monitoring of seclusion room despite CCTV being available
- Medication-induced swallowing difficulties and sedation
- Poor dentition without dentures
- Failure to conduct regular direct observation and verbal communication with secluded patient
- Lack of continuous face-to-face observation capability in seclusion room design
- Inadequate scrutiny of CCTV monitor by nursing staff
- Haphazard and inconsistent adherence to observation procedures
- Unreliable observation chart documentation
- Failure to report seclusion episodes exceeding 12 hours to Chief Psychiatrist
- Delayed detection of collapse and commencement of resuscitation
Coroner's recommendations
- Implement measures from the revised Restraint and Seclusion in Mental Health Services Policy Guideline (2015) in all psychiatric intensive care units in South Australia, including: continuous face-to-face visual observation of secluded patients; 15-minutely observation of behaviour; 15-minutely verbal contact to assess ongoing need for seclusion; medical review after one hour and at four hours with consultant psychiatrist notification; consultant psychiatrist review at eight hours
- Replace seclusion room doors with doors enabling constant visual observation by staff sitting outside the room (as has now been implemented)
- Implement more stringent documentation requirements for each observation point including comment on behaviour, conversation, and whether food, fluid, medication or toileting were offered and/or received
- Establish continuous monitoring of CCTV screens in seclusion areas with designated responsibility and regular checks to ensure vigilance
- When considering providing food to a secluded patient, staff should assess medication effects, patient agitation state, and dentition status before providing unsupervised food; if patient is incapable of safe consumption, consider release from seclusion
- Ensure seclusion episodes exceeding 12 hours and total seclusion exceeding 24 hours in 72 hours are reported to the Office of the Chief Psychiatrist and Director of Clinical Services as required by Mental Health Act 2009
- Implement the Chief Psychiatrist Standard relating to Restraint and Seclusion Recording and Reporting across all services, including entry of all seclusion incidents into the Safety Learning System
- Provide clear written guidance and training to all staff on seclusion observation requirements, clarifying that CCTV monitoring must be continuous and not merely at 15-minute intervals, and that direct communication with the patient is mandatory every 15 minutes
- Direct recommendations to Chief Executive of SA Health for implementation across all psychiatric intensive care units in South Australia
Full text
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