Finding into death of Peter James Nolan

Contributing factors

• High suicide risk not adequately managed despite 15-minute observation orders
• Blue slip sheet used as temporary curtain presented unrecognised ligature risk
• No risk analysis undertaken of using slip sheet as curtain in high-risk patient's room
• Lack of systematic ligature hazard identification and audit procedures
• Inadequate actual conduct of prescribed 15-minute close observations, particularly after 6:30am
• Observations not documented after 6:30am despite continued high-risk status
• Two nursing staff supervising 19 patients with competing duties during early morning shift
• Staff distraction due to waking patients and other duties limited supervision capacity
• Deteriorated mental state from depression, recent loss, physical illness, chronic pain, alcohol dependence
• Recent impulsive suicide attempts indicating high risk requiring close monitoring

Coroner's recommendations

1. Development of a systematic schedule of auditing, documenting, reporting and actioning recommendations to identify and address ligature points
2. Development of local education and training sessions on ligature identification and risk
3. Review of current design and investigative alternative options for reducing ligature risks
4. Implementation of an improvement programme (such as productive ward programme) to ensure decisions regarding ligature risk are fully implemented and kept up to date
5. Development of local procedure to ensure all staff and executive are aware of their responsibilities when responding to emergency codes
6. Incorporation of local education and training schedules with simulated code blue sessions for staff to increase confidence
7. Ensure ligature cutters are available to staff and that staff are trained in their use