Deceased
AH
Demographics
37y, female
Date of death
2013-11-24
Finding date
2017-08-22
Cause of death
asphyxia due to hanging
AI-generated summary
A 37-year-old woman with major depression and Crohn's disease was admitted to hospital following a suicide attempt. She was discharged after less than two days following clinical improvement, against her husband's reservations. She died by suicide three days later. The coroner found the discharge decision was premature and insufficiently informed. Key failures included: (1) Dr R. did not adequately assess risk by failing to obtain a separate history from the patient's husband before discharge, despite the patient being at an isolated rural location with four young children requiring her care; (2) the diagnosis should have been major depression rather than adjustment disorder, elevating suicide risk; (3) the transfer of care form to the Crisis Assessment and Treatment team was not sent, preventing timely community follow-up within 48 hours that might have identified clinical deterioration the following day.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
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