Finding into death of Maria Teresa Nigro
Deceased
Maria Teresa Nigro
Demographics
53y, female
Date of death
2009-02-10
Finding date
2015-04-02
Cause of death
hanging
AI-generated summary
Maria Nigro, a 53-year-old woman with depression and recent medication overdose, was admitted involuntarily to Werribee Mercy Hospital's Low Dependency Unit (LDU) on 4 February 2009. Despite a risk assessment on 9 February 2009 that scored her with no suicidal ideation, she died by hanging that night using a dressing gown cord. Key clinical shortfalls identified: (1) nursing observations reduced to hourly at night despite standard practice recommendations; (2) family conflict during a visit was noted but inadequately communicated at shift handover; (3) items capable of self-harm were not removed despite her involuntary status and recent suicide attempt; (4) an inexperienced enrolled nurse used non-standard observation techniques; (5) a confusing sleep chart made it unclear whether she was actually asleep during night checks. The coroner found the death preventable, though not necessarily preventable on that specific night, and recommended policies for removing harmful items and educating staff on individual risk management.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Procedures
Contributing factors
- inadequate communication at shift handover regarding family conflict
- failure to remove items capable of self-harm (dressing gown cord) despite involuntary admission status
- reduced overnight observations from half-hourly to hourly without individualised risk assessment
- non-standard observation techniques by inexperienced enrolled nurse
- confusing sleep chart documentation
- external stressor (family conflict) not adequately recognised or managed
- lack of monitoring and mentoring of junior nursing staff
- insufficient nursing staff induction into ward procedures and policies
Coroner's recommendations
- Mercy Health should develop and implement policies and procedures for the Low Dependency Unit whereby access to items that may be used to self-harm are removed or reduced, including checking patients and the unit for potentially harmful belongings, monitoring items brought in by visitors, and educating visitors on associated risks
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