Finding into death of WJ
Deceased
WJ
Demographics
39y, female
Date of death
2012-04-27
Finding date
2015-08-06
Cause of death
Hypoxic brain injury secondary to hanging
AI-generated summary
A 39-year-old woman with depression, anxiety, and substance use disorder was voluntarily admitted to Northern Hospital's psychiatric unit after presenting to ED with suicidal ideation. Despite documented suicidal thinking at admission, she was assessed as low-risk and placed in the Low Dependency Unit without routine removal of potential ligatures. Critical clinical gaps: no daily formal risk assessments conducted (only ad-hoc progress notes), failure to explore her stated suicide plan, undocumented changes to observation levels, and patient access to a dressing gown cord. Six days after admission, she hanged herself in an ensuite bathroom and was found unresponsive at 6am. Despite prompt resuscitation and ICU care, she suffered severe hypoxic brain injury and died 7 days later. While the coroner identified process failures requiring remediation, she was not satisfied these would have prevented this death. The hospital subsequently implemented policy requiring removal of potential ligatures from all psychiatric inpatients.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- Inadequate daily formal risk assessments
- Lack of documented formal risk reassessments after initial assessment
- Failure to explore suicide plan formulated on 17 April 2012
- Patient's reassurance about protecting her children may have prevented further risk exploration
- Inadequate documentation of changes to observation levels and reasons for changes
- Unexplained reversal of upgraded observations from medium to low risk
- Hospital policy did not require routine removal of ligatures from low-risk psychiatric patients
- Access to potential ligature (dressing gown cord in ensuite bathroom)
- First presentation to public mental health service with complex presentation
Coroner's recommendations
- NorthWestern Mental Health to redraft the policy 'Removal of Hazardous Items in Inpatient Units' to clarify terminology (use 'potential ligatures' instead of 'scarves'), specifically mention dressing gown cords, shoelaces, belts and headphone cords, and remove ambiguous language that could qualify the prohibition
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —