Finding into death of Patricia Webster
Deceased
Patricia Coral Webster
Demographics
41y, female
Date of death
2009-11-13
Finding date
2011-08-09
Cause of death
Hanging
AI-generated summary
Patricia Webster, a 41-year-old with a history of major depressive disorder, was admitted to hospital on 8 October 2009 after stopping antidepressants. She was discharged on 21 October with community mental health follow-up. On 12 November, her husband reported she had a rope and expressed wanting to hang herself. A safety plan was agreed after she denied current suicidal intent, but there was a critical breakdown in communication about the plan's details—specifically regarding supervision arrangements, appointment times, and transport responsibilities. The family did not appreciate the degree of risk and Mrs Webster was left unsupervised, allowing her to access a ligature and complete suicide on 13 November. The coroner identified inadequate communication from mental health staff to the family about risk assessment and safety plan expectations as a key contributing factor. When relying on family to supervise high-risk patients, explicit, unambiguous education about risk level and expectations is essential.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- Breakdown in communication of safety plan details to family
- Family did not appreciate degree of risk of self-harm
- Patient left unsupervised at home
- Inadequate communication from mental health service to family about risk level and expectations
- Reliance on family supervision without clear education about risk
Coroner's recommendations
- Mental health services should provide higher level of education to families when relying on carers and family members for observational activities to keep patients with suicidal ideation safe
- Communication of expectations by mental health services and crisis protocols must be clear and unambiguous when family members are involved in patient safety
- Mental health services should not assume families will appreciate risk to the same degree as professionals without explicit communication
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