Deceased
Gerard Ernest Stefaniw
Demographics
63y, male
Date of death
2016-10-21
Finding date
2019-01-18
Cause of death
asphyxia caused by hanging
AI-generated summary
Gerard Ernest Stefaniw, a 63-year-old man with cerebral palsy, cognitive impairment, and chronic pain, died by asphyxiation while detained at Roy Fagan Centre. He was unhappy about his guardianship order and detention. A solicitor provided him with an adverse psychological assessment on 19 October 2016. The solicitor informed Clinical Nurse Consultant Colin Brett that Mr Stefaniw might need extra observation, but Brett failed to communicate this concern to other staff or document it. No staff member on duty knew of the adverse report. While increased surveillance would have been difficult given his agitation, the failure to communicate the warning meant staff had no reason to deviate from routine checking. The coroner found the facility's care generally appropriate but noted this critical communication failure. No specific recommendations were made, as the facility had already implemented improvements including staff training and removal of hanging points.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
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