Finding into death of TK

Contributing factors

• Bathroom door hooks/housing designed for wall mounting but installed on psychiatric facility bathroom doors posed an unacceptable hanging risk
• Failure of internal safety audit processes to identify the unacceptable risk posed by hooks/housing
• Inadequate risk management documentation following a co-patient's prior hanging attempt using the same hooks
• Discrepant risk assessments between outpatient and inpatient teams regarding acuity of suicidal risk
• Breakdown in communication regarding safety concerns about hooks/housing raised by staff but not formally escalated

Coroner's recommendations

1. The Chief Psychiatrist should consider mandating the removal of the particular hook/housing used in the Orygen inpatient unit, particularly from doors or any other placement where they can be utilised as a hanging or suspension point.
2. Orygen Youth Health/Melbourne Health should develop a procedure that addresses the need for scene preservation and/or recording, in circumstances where a serious suicide attempt has taken place in an inpatient facility, in anticipation of a foreseeable coronial investigation.
3. Such a procedure should identify roles and responsibilities as clearly as possible, in particular as regards the completion of RiskMan reports of the incident or any other tool or software being used from time to time in the health service to manage risk.
4. The health service should contact the court for information regarding a guideline being developed by the Chief Commissioner of Police to assist health services with scene preservation procedures.