Coroner's Finding: Bunn, Lauren Elizabeth
Deceased
Lauren Elizabeth Bunn
Demographics
25y, female
Date of death
2016-10-13
Finding date
2018-03-05
Cause of death
mixed drug toxicity
AI-generated summary
Lauren Elizabeth Bunn, aged 25, died by voluntary ingestion of mixed drugs in October 2016. She had a longstanding history of serious mental illness with multiple documented suicide attempts and police welfare checks in the months preceding her death. After calling a counsellor from Rural Alive and Well reporting overdose and suicidal intent, a critical delay occurred: the police dispatch operator failed to simultaneously request an ambulance despite credible information suggesting overdose and toxicity signs (slurred speech). Police arrived 45 minutes later; ambulance arrived over 30 minutes after that. The coroner found this delay unnecessary and preventable. Key learning: dispatch protocols must include triggers for simultaneous ambulance requests when suicide attempts are reported, particularly from mental health services. Current RDS procedures referenced only Lifeline but not services like Rural Alive and Well, contributing to the gap.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- failure of police dispatch operator to request ambulance simultaneously with police dispatch
- delay in ambulance arrival of over 30 minutes
- RDS policies and procedures gap - procedures only referenced Lifeline, not other mental health services such as Rural Alive and Well
- medication non-compliance
- history of serious mental illness with suicidal ideation
Coroner's recommendations
- Tasmania Police review the applicable RDS policies and procedures dealing with the circumstances in which an ambulance is to be dispatched to reported suicide attempts
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