Finding into death of Maree Rosalie Jones

Contributing factors

• lack of removal of pyjama cord during transfer from Extra Care Unit to Low Dependency Unit
• plastic bags not identified as dangerous items and not prohibited in Low Dependency Unit
• inadequate assessment of patient belongings against individual patient risk history
• default position of allowing potentially dangerous items rather than individual risk assessment
• patient had explicitly discussed method of plastic bag asphyxiation with husband but this information not reflected in safety planning
• search of belongings on transfer not mandated by policy at time
• recording of 15-minute observations not synchronous with actual observations, though observations themselves were carried out
• limited night shift staffing (three staff for two units)

Coroner's recommendations

1. Adopt Coroner Spanos' recommendation and change current policy that allows patients in the Low Dependency Unit to retain items capable of being used as a ligature
2. Ensure St Vincent's Mental Health takes a consistent approach with North West Mental Health regarding prohibited items in acute inpatient units
3. Improve search procedures for patient belongings when transferring between units, particularly identification of specific risk factors for individual patients