Deceased
David Edward Chessell
Demographics
43y, male
Date of death
2017-12-10
Finding date
2023-09-20
Cause of death
compression of the neck due to hanging
AI-generated summary
A 43-year-old male veteran died by hanging in a psychiatric inpatient unit while under a Level 2 Inpatient Treatment Order. He was admitted after a high-lethality suicide attempt involving overdose and carbon monoxide exposure, presenting with major depression and active suicidal ideation. Death occurred two days after escalation to Level 2 ITO. Clinical observations were conducted at 60-minute intervals despite risk being elevated from low to medium on the morning of death. The deceased hanged himself using a bedsheet ligature from a known high-risk handrail in a shower cubicle. No nursing staff observed him for at least 53 minutes before discovery. The facility had multiple documented ligature risks that had not been formally escalated to senior management despite being identified in audits. While the ITO was lawful and appropriate, environmental safety failures and inadequate observation frequency contributed to a preventable death in a facility deemed unfit for purpose.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Male·suicide
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