Finding into death of Sarolta Elesits
Deceased
Sarolta Elesits
Demographics
54y, female
Date of death
2009-01-08
Finding date
2013-09-12
Cause of death
Acute alcohol toxicity with immersion
AI-generated summary
A 54-year-old woman with major depressive disorder and alcohol addiction died from acute alcohol toxicity with immersion. She was hospitalised involuntarily on 23 December 2008 with a blood alcohol level of 0.323 and suicidal ideation, then discharged on 1 January 2009 without involuntary status. The coroner identified a critical breakdown in communication between two mental health teams (CATT and Clayton Community Mental Health Service). There was an expectation that CATT would monitor her until her case manager returned from leave, but this expectation was not communicated to CATT. Consequently, no follow-up occurred on 7-8 January when she was found dead. The coroner could not be comfortably satisfied that timely follow-up would have prevented her death, and could not determine whether it was suicide or accident. Southern Health implemented new protocols to prevent similar communication failures.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- breakdown in communication between CATT and Clayton Community Mental Health Service
- failure to convey expectation of continued monitoring by CATT
- major depressive disorder with chronic suicidal ideation
- severe alcohol addiction
- extraordinarily high blood alcohol concentration (0.54g/100ml vitreous)
- case manager and psychiatrist on leave
Coroner's recommendations
- Southern Health to implement Transfer and Discharge in Mental Health protocol
- Southern Health to implement Principles for Referral Processes from CATT to Continuing Care, and Continuing Care to CATT protocol
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 —