Finding into death of Lisa Irene Sharp
Deceased
LISA IRENE SHARP
Demographics
34y, female
Date of death
2007-12-17
Finding date
2011-08-16
Cause of death
Hanging with combined effects of ethanol and benzodiazepines
AI-generated summary
Lisa Sharp, 34-year-old woman on a Community Treatment Order for schizophrenia, depression, and anxiety, died by hanging on 16-17 December 2007. She was in severe distress over losing custody of her children, with a court hearing scheduled for 14 December. Police attended her home on 15 December after she threatened hanging; she was transported to Maroondah Hospital and assessed by psychiatric nurse Gary Cox about 4 hours after arrival. Mr Cox did not conduct a formal mental state examination or risk assessment despite knowing of her recent attempted hanging, focusing instead on her requests for benzodiazepines. He discharged her with a plan for her to contact her case manager. Critical failures included: Mr Cox's failure to fully assess her suicide risk despite recent hanging attempt and documented high vulnerability; inadequate handover of critical ambulance information; lack of coordinated follow-up by her mental health team after her court case, which the team knew was a major stressor; and failure to provide transport home or verify medication access. The coroner found deficiencies in care and assessment.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- Inadequate mental state examination and risk assessment by psychiatric nurse
- Failure to incorporate collateral information from ambulance records
- Failure to document or assess recent suicide attempt (hanging)
- Lack of follow-up after major stressor (children's court hearing)
- Restriction of benzodiazepines without monitoring for withdrawal or deterioration
- No contact from treating team after court case despite identified stressors
- Inadequate discharge planning without formal risk assessment
- Four-hour delay between triage and psychiatric assessment
- Poor communication between emergency department and community mental health services
- Lack of supervised transport arrangement despite patient vulnerability and disorganisation
- Failure to verify medication access at discharge
Coroner's recommendations
- Eastern Health Mental Health Services should review current guidelines for patients presenting to Emergency Departments with mental health crises to comply with Department of Health 2010 'Working with the suicidal person' guidelines, with particular emphasis on ensuring formal assessment of suicide risk and mental state examination are completed and clearly documented
- Eastern Health Mental Health Services should develop clear guidelines for timely review by community mental health services of patients who have undergone assessment and are consequently discharged
- Eastern Health Mental Health Services should review current guidelines regarding how best to support a case-managed patient on a Community Treatment Order when there are custody issues pertaining to the patient
- Finding should be distributed to Department of Human Services and Department of Health, Mental Health Drugs and Regions Division
Full text
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