Deceased
Sarolta Elesits
Demographics
54y, female
Coroner
Coroner Phillip Byrne
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. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
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