Coroner's Finding: de-identified FG
Demographics
57y, male
Date of death
2020-09-30
Finding date
2024-11-26
Cause of death
partially suspended hanging
AI-generated summary
A 57-year-old man with longstanding alcohol use disorder, anxiety, and recent-onset suicidal ideation died by hanging in hospital after a 108-day admission for orthopaedic injuries sustained from intentional jumping. He had complex neurocognitive impairment (dementia, delirium, alcohol-related brain injury) and personality features. Key clinical lessons: (1) Prolonged stays on non-psychiatric wards for patients with high suicide risk require enhanced environmental safety measures including regular searches for means; (2) When multiple teams provide fragmented care without clear leadership, critical decisions about diagnosis, level of care, and discharge planning may be delayed—escalation protocols to senior decision-makers are essential; (3) Communication with families about irreversible cognitive impairment and poor prognosis should be explicit and unambiguous; (4) Patients with alcohol-related neurocognitive disorder and impulsive suicide history need structured, protected environments even when acute psychiatric diagnoses are disputed.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- neurocognitive disorder (dementia, delirium, alcohol-related brain injury)
- alcohol use disorder
- chronic suicidal ideation with impulsive attempts
- borderline personality traits
- psychosocial stressors (loss of work role, marriage breakdown)
- lack of environmental safety measures on orthopaedic ward
- fragmented multidisciplinary care without clear clinical leadership
- prolonged hospital stay pending discharge planning
- access to means (electrical cord brought into hospital)
Coroner's recommendations
- Develop a statewide protocol for searching individual patients and their immediate physical environment to minimise risk of harm, and ensure all relevant staff have working knowledge of and can conduct effective searches
- Regularly review the operation of the Complex Patient Committee and other escalation processes to ensure treating teams understand and use protocols for escalating treatment, care and discharge planning decisions
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