Finding into death of Naomi Charmaine Mahon
Deceased
Naomi Charmaine Mahon
Demographics
33y, female
Date of death
2011-04-08
Finding date
2015-05-28
Cause of death
multiple injuries sustained when struck by a train
AI-generated summary
Naomi Mahon, a 33-year-old woman with bipolar affective disorder and substance use issues, died after being struck by a train shortly after absconding from Monash Medical Centre emergency department. She had been brought to the ED by police under Mental Health Act section 10 after threatening suicide. The psychiatric team assessed her as not meeting involuntary treatment criteria and admitted her voluntarily to the psychiatric ward. While waiting for medical clearance, she impulsively ran from the ED when clinical staff turned away briefly. The coroner found no clinical deficiency caused her death, but commented that such preventable deaths after ED absconding remain an ongoing coronial concern. Key clinical lesson: the balance between respecting autonomy and recognizing that patients presenting as cooperative may still pose flight risks in high-risk mental health presentations.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Contributing factors
- psychiatric illness
- effects of cannabis use
- absconding from emergency department
- impulsive decision-making
- untreated akathisia
- limited insight into mental illness
Coroner's recommendations
- Continue implementation of recommendations from Monash Medical Centre's internal review following Ms Mahon's death, including timely conduct of risk assessments, identification of 'high risk' patients, types of information used in risk assessments, and documentation of risk assessments
- Consideration of enhanced risk assessment protocols for patients presenting as cooperative but with recent history of flight risk or agitation in psychiatric presentations
Full text
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