Deceased
Naomi Eva-May Hall
Demographics
37y, female
Date of death
2009-11-27
Finding date
2013-06-12
Cause of death
head injury sustained in motor vehicle collision (pedestrian)
AI-generated summary
A 37-year-old involuntary psychiatric patient with paranoid psychosis absconded from the low-dependency psychiatric unit at Maroondah Hospital and deliberately stepped in front of a truck, suffering fatal head injuries. The coroner found the clinical transfer from high-dependency to low-dependency care was appropriate and the patient's absconding could not have been reasonably foreseen. However, the finding highlights a systemic issue identified in multiple coronial investigations: nursing observation levels were reduced from 30 to 60 minutes without documented medical practitioner agreement. Eastern Health subsequently implemented improvements to risk assessment processes and education around observation protocols to ensure observation level changes require explicit clinical authorization. The death was ultimately due to the patient's deliberate act while suffering acute psychosis.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Procedures
40y · Male·Unascertained
Nathan James Taylor, aged 40, died in Port Lincoln Prison on 24 March 2022 while in custody pending trial on witness interference charges. He had significant medical history including infective endocarditis with tricuspi…
36y · Male·Drowning
Gary Dale Sargeant, a 36-year-old Royal Australian Air Force member, died by drowning after absconding from Edinburgh Health Centre during an acute mental health crisis. Critical clinical failures included: a clinical ps…
59y · Male·Multiple injuries
Martin Carl Quiterio, a 59-year-old man with longstanding schizophrenia and suspected autism spectrum disorder, died on 3 January 2024 when he jumped from the 14th floor of a car park in West Perth. He had been discharge…
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