Deceased
Kelvin Robert Davidson
Demographics
75y, male
Date of death
2007-10-04
Finding date
2014-09-29
Cause of death
Hanging
AI-generated summary
Kelvin Davidson, a 75-year-old man with complex psychiatric history including prior self-harm and attempted hanging, was admitted to Baringa Aged Psychiatric Unit on 27 September 2007. He engaged in wrist-cutting self-harm 48 hours after admission and was transferred to Alfred Hospital then returned with one-to-one nursing. On 2 October, his one-to-one overnight observations were discontinued by Dr T. as he had not expressed further self-harm ideation. He died by hanging on 4 October while on 15-minute observations. The coroner found the risk assessment, handrails, and audit procedures reasonable, and that the observation downgrade was clinically justified based on available evidence. However, recommendations were made requiring consultant medical officer in-person review and documentation prior to observation downgrades, with IT-timestamped approval systems when unavailable.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
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