Finding into death of Evelyn Wright
Deceased
Evelyn Faye Scherger
Demographics
62y, female
Date of death
2011-09-06
Finding date
2013-04-22
Cause of death
Hypoxic brain injury complicating mixed drug toxicity
AI-generated summary
Evelyn Faye Scherger (62F) died from hypoxic brain injury following a polypharmacy overdose on 6 September 2011, two days after discharge from the Mildura Base Hospital Emergency Department. She had presented after a suspected overdose of prescription medications on 5 September in the context of severe marital breakdown and a prior serious suicide attempt in July. The coroner found her suicide risk was assessed as moderate and she was discharged with follow-up psychiatric appointment the next day. Critical clinical lessons: suicide risk assessment should weight objective facts and behavioural inconsistencies more heavily than patient self-reporting; family concerns ('grain of salt' principle) warrant consideration alongside clinical judgement; discharge planning must involve family carers and provide explicit safety instructions; consultant psychiatrists reviewing cases after hours need documented access to full medical notes, not just verbal telephone relay; medication access requires coordination between hospital and primary care systems.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- Misassessment of suicide risk as moderate rather than high
- Over-reliance on patient self-reporting and denial of suicidal intent
- Inadequate weighting of objective behavioural facts indicating planned suicide attempt
- Insufficient incorporation of family concerns into risk assessment
- Inadequate discharge planning and care coordination with family carers
- Verbal-only communication between CATT clinician and off-site consultant psychiatrist without documented full information transfer
- Failure to clarify actual discharge care arrangements with family
- Lack of explicit safety instructions provided to family care provider
- Unmonitored access to significant quantity of loose prescription medication
- Prior recent prescription of Xanax by alternative GP without mental health system coordination
Coroner's recommendations
- The Office of the Chief Psychiatrist, Minister for Health and/or Secretary to the Department of Health should review Risk Assessment tools to prompt clinicians to consider the credibility of answers provided by a patient and to weight these factors accordingly
- The Minister for Health and/or Secretary to the Department of Health should consider providing a statutory capacity in the Mental Health Act to enable a limited 24 hour assessment and safety order to enable more thorough assessment of suicide risk and safety planning
- The Northern Mallee Area Mental Health Service should review and modify its Guide to ensure processes are implemented so that views of family and friends be given great weight prior to finalisation of decisions, such as meeting with relevant family to discuss preliminary decisions
- The Northern Mallee Area Mental Health Service should review and modify its Guide to ensure documented care planning with family and friends who will be involved in consumer care post discharge
- The Northern Mallee Area Mental Health Service should consider improving documented information available to off-site Consultant Psychiatrists including relevant medical notes, MHS Screening Register, CATT Clinician Risk Assessment and Assessment Notes via scanning and tablet technology
- The Minister for Health and/or Secretary to the Department of Health should investigate ways to prevent Mental Health Service patients from being prescribed additional medication from general practitioners without notification to the Mental Health Service
- The Mildura Base Hospital should implement a procedure to record the action taken with regard to patient medication upon discharge
Full text
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