Finding into death of Lee Patrica Collings
Deceased
Lee Patricia Collings
Demographics
51y, female
Date of death
2007-03-25
Finding date
2012-01-31
Cause of death
Multiple injuries sustained when struck by a car while lying on the Mornington Peninsula Freeway
AI-generated summary
Lee Collings, 51, died by suicide after absconding from an Emergency Department. She presented with suicidal ideation and was triaged as Mental Health Category 4. Key failures included: the Crisis Assessment Team clinician had no knowledge of her three Emergency Department presentations in three days due to unavailable computer systems and paper-based records; her recent history would have warranted higher triage category; and she was permitted unsupervised smoking breaks despite high suicide risk. The clinician delayed formal risk assessment until she was sober, but approved her unsupervised movement. System failures in record access, lack of integrated assessment for alcohol-intoxicated suicidal patients, and single clinician coverage during busy periods contributed to her death. Earlier access to records and appropriate supervision may have prevented this outcome.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- inadequate record access due to non-urgent retrieval system and computer system unavailability
- lack of knowledge of three recent Emergency Department presentations for suicide attempts
- computer system (Mental Health Client Management Interface) malfunction on weekend
- inadequate supervision of patient permitted unsupervised smoking breaks
- single Crisis Assessment Team clinician managing four mental health patients on Saturday afternoon
- delay in formal risk assessment due to elevated blood alcohol concentration
- misrecording of ambulance assessment
- lack of integration between mental health triage clinic and Emergency Department
- paper-based dual record system preventing easy access to mental health history
- absence of frequent presenter alert system in 2007
- triage category 4 classification did not trigger priority record retrieval
Coroner's recommendations
- The Chief Psychiatrist should advise Emergency Department mental health clinicians to routinely and regularly re-assess patients who present with a history of self harm and with a high blood alcohol concentration in order to more accurately determine factors likely to predict risk of absconding and suicide
- The Minister for Health should acknowledge that mental health and overdose patients are over-represented in Emergency Department Frequent Presenter populations and ensure that all Emergency Department mental health and overdose presentations are recorded electronically in databases accessible to subsequent treating mental health clinicians
- The Australasian College of Emergency Medicine and the Royal Australian College of Nursing should advise Emergency Department triage staff to maintain and access the electronic record of patients presenting with mental health issues as part of their triage assessment
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —