Finding into death of Wieslaw Albin Bernacki
Deceased
Wieslaw Albin Bernacki
Demographics
62y, male
Date of death
2009-12-30
Finding date
2014-12-05
Cause of death
hanging
AI-generated summary
A 62-year-old man with a long history of severe schizophrenia died by hanging after being granted escorted day leave from a psychiatric inpatient unit. The coroner identified critical failures in communication between hospital staff and the civilian escorts regarding the nature and extent of supervision required. Escorts were not given adequate information about their responsibilities, crisis management procedures, or why the leave was designated as 'escorted' rather than unescorted. Additionally, staff delayed significantly in responding to the patient's failure to return—waiting approximately 5 hours before reporting him missing to police. A change in sleep pattern overnight before leave was noted but not adequately explored. The coroner found these failures created an opportunity for the death to occur, though the decision to grant leave itself was clinically reasonable based on assessments at the time. Key improvements needed include proper briefing of escorts, documentation of arrangements, and timely escalation when patients fail to return from approved leave.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- inadequate communication between hospital staff and leave escorts regarding responsibilities and supervision requirements
- failure to properly explain the nature and purpose of escorted leave to escorts
- poor documentation of leave arrangements and escort contact details
- lack of crisis management information provided to escorts
- delayed response to patient's failure to return from leave (5-hour delay before police involvement)
- insufficient exploration of change in patient's sleep pattern overnight before leave
- lack of identifying information about escorts in patient notes
- no documented contact details or names of escorts
Coroner's recommendations
- Mercy Mental Health review its Client Leave Procedure to ensure compliance with the Chief Psychiatrist's September 2009 Guideline on Inpatient Leave of Absence, with particular emphasis on requirements for communicating responsibilities to leave escorts and recording crisis information
- Mercy Mental Health review its Absconded Psychiatric Clients Protocol to ensure it contains a clear process and mandates a timely response to a patient's failure to return from an approved leave of absence
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