Coroner's Finding: Paxford, Mathew George
Deceased
Mathew George Paxford
Demographics
27y, male
Date of death
2016-03-24
Finding date
2023-03-03
Cause of death
hanging
AI-generated summary
A 27-year-old man with deteriorating mental health and acute psychotic symptoms died by hanging from a bathroom door in an acute mental health unit. He had expressed suicidal ideation, told his parents he needed to die to protect them, and made a farewell phone call to say goodbye. Clinical staff appropriately decided to implement an Inpatient Treatment Order and increase observations to 15-minute intervals. However, he was left alone for 10-20 minutes while paperwork was being completed, during which time he hanged himself using a bedsheet from the ensuite bathroom door. The coroner found he should not have been left unattended given the accumulated evidence of suicide risk, though strict 15-minute observation alone may not have prevented death. The bathroom door had not been identified as a ligature point in a pre-opening audit, despite known risks. Key clinical lessons include recognising escalating suicide risk, maintaining continuous observation in acute high-risk situations, and identifying and managing ligature points in mental health facilities.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- failure to identify bathroom door as ligature point in audit
- patient left unattended despite high suicide risk
- inadequate observation frequency given accumulated risk
- concern focused on absconding rather than in-room self-harm
- psychotic symptoms with paranoid ideation
- acute mental health deterioration
- suicidal ideation expressed to nursing staff
- farewell phone call to parents
- statement to parents that he needed to die to protect them
Coroner's recommendations
- To the Minister for Health and Wellbeing: ensuite bathroom doors in acute inpatient mental health units should be reviewed to identify potential ligature points and be removed, modified or replaced to eliminate potential ligature points
Full text
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