Finding into death of Esther Ng Kit Ching
Deceased
Esther Ng Kit Ching
Demographics
53y, female
Date of death
2012-11-13
Finding date
2017-02-07
Cause of death
Hypoxic brain injury due to hanging
AI-generated summary
A 53-year-old woman with severe depression, anxiety, and recent suicide attempt died by hanging in a psychiatric hospital's low-dependency unit. She had received ECT and was on hourly observations. On the day of her death, her husband reported new agitated pacing behaviour and significant anxiety before leaving at 6:30 pm. The nursing staff member failed to escalate her deteriorating mental state to senior staff or implement one-to-one care despite concerning behavioural changes and her husband's explicit concerns. Critical failures included incomplete mental state assessment, lack of escalation when new agitation appeared, failure to communicate concerns to the next shift, and access to ligature points and materials. The coroner found the death could have been prevented with appropriate escalation and closer monitoring when her mental state worsened.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Procedures
Contributing factors
- Failure to escalate deteriorating mental state to senior staff
- Failure to implement one-to-one care despite new agitated behaviour
- Incomplete mental state assessment by duty nurse
- Failure to communicate concerning observations to incoming night shift staff
- Accessibility of ligature points (bathroom door with hanging points)
- Availability of dressing gown cord (potentially dangerous item)
- Nursing staff distracted by Code Grey security incident
- Patient guarded presentation limiting assessment
- Pressure on nursing staff and suboptimal system processes
- Absence of uniform management approach to dangerous personal items
Coroner's recommendations
- Eastern Health should amend its protocol to emphasize the dangerous aspects of allowing patients in the LDU to bring in belts, cords or similar items that may be used as ligatures, and institute admission and periodic search policies to ensure rigorous management of this issue
- Eastern Health should maintain its ligature review process but ensure that a person properly qualified in psychiatric unit risk management analysis who is not part of Eastern Health hospital administration is engaged to assist in that work
- Eastern Health should provide direction to senior staff regarding nomination of a designated person within each unit to collect, preserve and provide safekeeping of all materials relevant to any investigation into suspected self-harm incidents, with the Nurse Unit Manager identified as a suitable designated person
- Upton House nursing staff should be counselled as to the importance of making clinical notes and completing clinical records
Full text
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