Finding into death of Amy Hauserman
Deceased
Amy Wyatt Hauserman
Demographics
26y, female
Date of death
2008-03-16
Finding date
2013-07-26
Cause of death
Hypoxic brain injury in the setting of immersion
AI-generated summary
Amy Hauserman, a 26-year-old woman with schizophrenia and anorexia, was admitted to a psychiatric ward with acute psychosis due to non-compliance with clozapine. Over two days, she developed severe abdominal pain and constipation unresponsive to medical management. Nursing staff offered her a bath to relieve discomfort. No formal risk assessment was completed despite protocols suggesting this was necessary. Amy was found face-down in the bath after 15-minute observations resumed. She was not rescued promptly due to lack of direct bathroom supervision. The coroner found the decision to permit unsupervised bathing was made in error, given her multiple risk factors: severe constipation, recent diazepam use, drowsiness, poor mental state, and possible medication withdrawal effects. The absence of constant supervision was the primary factor preventing timely rescue.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- Acute psychosis due to medication non-compliance
- Severe constipation and abdominal pain
- Diazepam intake causing drowsiness
- Poor mental and physical state
- Potential medication withdrawal effects
- Absence of formal risk assessment before bathing
- Lack of direct bathroom supervision during bathing
- Failure to escalate concerns about unusual movements to senior staff
- Inadequate nursing training on bathing protocols
- Inability to prompt rescue due to distance from bathroom
Coroner's recommendations
- Mandatory written risk assessment before offering bath to patients requiring frequent observations, addressing medical risk, cognitive impairment, risk of fall, and suicide risk
- Constant direct visual supervision of patients in psychiatric wards during bathing if baths are permitted
- Clinical practice guidelines incorporating mandatory supervision requirements and risk assessment procedures
- Improved training on bathing protocols and observation requirements
- Observation protocols must be carried out by direct visual observation with oral contact, not through doorways or curtains
- Patients should be offered choice between supervised bath or no bath, with safety paramount over privacy
- Consultation with treating psychiatrist before offering bath to psychiatric patients with complex presentations
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