Finding into death of Joseph Pezzimenti
Deceased
Joseph Pezzimenti
Demographics
60y, male
Date of death
2013-05-28
Finding date
2016-12-08
Cause of death
Global cerebral ischaemia post cardiac arrest in the setting of neck compression
AI-generated summary
Joseph Pezzimenti, a 60-year-old involuntary psychiatric patient, died from cerebral ischaemia following hanging by a tracksuit cord in a Low Dependency Unit bathroom. Key clinical lessons include: communication difficulties (voice loss) should not diminish suicide risk assessment—Dr B.'s assessment of 'no overt risks' despite multiple prior attempts was inadequate; treating teams must access complete medical records and prior suicide methods; ligature items must be removed from Low Dependency Units regardless of whether risk is deemed 'chronic' versus 'acute'; staff must be trained on and apply institutional risk assessment policies; and escalation to High Dependency Unit with 1:1 observations was warranted given his history. The coroner found reasonable clinical judgment in placement and communication adequacy, but criticised the absence of ligature removal protocols and staff unfamiliarity with risk assessment procedures.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- Access to ligature (tracksuit cord) in Low Dependency Unit
- Lack of policy regarding removal of potential ligature items
- Incomplete communication of risk assessment between treating teams
- Medical records not transferred from Community Care Unit to Inpatient Unit
- Staff unfamiliarity with institutional risk assessment and visual observation procedures
- Placement in Low Dependency Unit despite history of multiple suicide attempts
- Difficulty assessing suicide risk due to patient's voice loss and communication limitations
Coroner's recommendations
- Mercy Health must change its policy that allows patients in the Low Dependency Unit to retain items capable of being used as a ligature, consistent with Chief Psychiatrist's Guideline on Criteria for searches to maintain safety in an inpatient unit
- Items including plastic bags, scarves, belts, shoelaces and headphone cords must be removed from patients in inpatient units
- Psychiatric inpatient units should take a consistent approach and follow the position adopted by North West Mental Health and St Vincent's Hospital regarding ligature item removal
- Expedite transition to electronic medical records to ensure patient files follow patients between services
- Improve staff training and awareness of institutional risk assessment procedures and visual observation policies
- Develop specific admission assessment procedures detailing criteria for placement in High versus Low Dependency Units
Full text
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