Deceased
MARK RONALD CONNOLLY
Demographics
27y, male
Date of death
2009-08-17
Finding date
2011-12-02
Cause of death
HEAD INJURY SUSTAINED IN A MOTOR VEHICLE COLLISION (PEDESTRIAN)
AI-generated summary
Mark Connolly, 27, with paranoid schizophrenia and command hallucinations, was admitted to the Low Dependency Unit of a psychiatric hospital despite expressing intent to jump from a moving car and requesting High Dependency placement. He was placed on 15-minute observations but absconded via the courtyard fence within 45 minutes and was struck by a truck. Clinical lessons: discrepancies between documented (constant) and verbal (15-minute) observation orders created confusion; the observation nurse was unaware of the specific suicide risk; medication compliance wasn't verified at the prior home visit despite known non-compliance; and the courtyard fence was inadequately secured. The coroner found suboptimal care in observation protocols and risk communication, though no policy required continuous nurse accompaniment.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
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