Finding into death of Daniel John Woodburn
Deceased
Daniel John Woodburn
Demographics
22y, male
Date of death
2011-01-20
Finding date
2016-06-01
Cause of death
Multiple injuries secondary to fall from a height
AI-generated summary
Daniel Woodburn, a 22-year-old with first-episode psychosis presenting with command hallucinations, paranoia and depressed mood, was admitted as a voluntary patient to an unlocked inpatient unit at Orygen Youth Health on 19 January 2011. Critical clinical shortcomings were identified: no mental state assessment or meaningful engagement documented over 10 hours (9:45pm to 8:29am) despite nursing care plans specifying frequent engagement and risk monitoring; no medication administration despite paranoia-related disengagement; unclear communication about a 'low threshold' for involuntary status if patient attempted to leave. The patient absconded the next morning and died by suicide. While the coroner found the death could not be proven preventable with certainty, she identified significant failures in care delivery versus documented plans, inadequate engagement with an acutely unwell paranoid patient, and systemic gaps in staff briefing about risk management strategies.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- First episode psychosis with command hallucinations
- Paranoid ideation with patient disengagement from staff
- Depressed mood
- Acute onset mental illness
- Failure to provide documented mental state assessment and meaningful engagement over 10 hours
- Lack of documented staff communication about low threshold for involuntary status
- Admission to unlocked ward despite acute presentation
- Inadequate medication administration and assessment
Coroner's recommendations
- Orygen Youth Health to provide specific periodic training on Clinical Risk Assessment and Management (CRAAM) guidelines, including expectations of night staff to engage with patients where there is likely to be significant delay between admission and consultant psychiatrist assessment
- Chief Psychiatrist of Victoria to review whether guidelines should be issued by the Office of the Chief Psychiatrist providing guidance to clinicians on appropriate engagement with clients in multifactorial situations such as this, particularly on night shifts
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 —