Deceased
Carole Ann Le Roy
Demographics
40y, female
Date of death
2018-02-24
Finding date
2020-10-09
Cause of death
hypoxic encephalopathy due to asphyxia from hanging
AI-generated summary
A 40-year-old woman with extensive mental health history including OCD, complex trauma, severe depression, and recurrent suicidal ideation was admitted to an open psychiatric unit after expressing suicidal intent. Despite being assessed as high-risk with a management plan requiring hourly observations, she was placed in an open unit rather than high-dependency or closed unit. Critical failures included: non-implementation of the hourly observation plan, placement in a room with ligature-accessible fixtures, an internally lockable door delaying staff access, and her possession of a duffle bag strap. She died by hanging within 48 hours. The coroner found admission to the open unit was inappropriate given her presentation change from previous admissions, and that post-admission care fell significantly below expected standards. The hospital's own root cause analysis acknowledged chaotic governance, poor nursing processes, lack of team structure, and inadequate systematic risk management.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
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