Finding into death of Leanne Joan Howell
Deceased
LEANNE JOAN HOWELL
Demographics
40y, female
Date of death
2010-01-15
Finding date
2013-09-19
Cause of death
hanging
AI-generated summary
Leanne Howell, a 40-year-old woman with major depression and recent suicide attempts, died by hanging while on unescorted leave from an acute psychiatric unit. Critical protective conditions of her leave plan—including limiting duration to 2–3 hours and notifying her brother before release—were not documented, communicated to nursing staff, or complied with. She was released for approximately 5 hours without family notification. When her brother later raised concerns about non-compliance, this was not recorded or acted upon. The coroner found that had the leave plan been properly documented, communicated, and implemented, and her brother contacted as planned, the risk would have been substantially decreased. Key failures included inadequate documentation, poor communication between clinicians and nursing staff, lack of accountability for protocol adherence, and insufficient weight given to family member concerns despite policy requiring this.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- failure to document and communicate critical protective conditions of leave plan
- leave granted for 5 hours despite plan limiting to 2–3 hours
- failure to notify brother Andrew before release despite agreed plan
- inadequate documentation of leave conditions in Leave of Absence form
- failure to record or act upon brother's concerns about non-compliance
- inadequate mental state examination or risk assessment documentation
- lack of accountability and supervision of leave plan compliance
- provisional psychologist did not contribute to leave decision despite treating relationship and clinical knowledge
- reduction of observations from 15-minute to half-hourly intervals without clear justification
- falsified correspondence to Chief Psychiatrist regarding leave progression
Coroner's recommendations
- The Department of Health and Human Services ensure there is clear and consistent process, documentation and communication for Leave Plans. Any changes are to be made only after suitable discussion and consideration and such variations recorded and communicated.
- In addition to the above, the process and documentation of Leave Plans should incorporate supervision and accountability to ensure compliance by all mental health professionals involved in the granting and implementation of leave plans.
- That there be a process for ensuring the accuracy of information provided to the Chief Psychiatrist.
- Implement Recommendation 15 made in the report titled 'Chief Psychiatrist's investigation of inpatient deaths 2008–2010' that the Chief Psychiatrist convene a panel every three years to inquire into inpatient deaths over that time to consider overall practice improvements and issues relevant to the mental health system.
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