Deceased
Rebecca Victoria Poke
Demographics
29y, female
Date of death
2015-09-02
Finding date
2016
Cause of death
global cerebral ischaemic injury in the setting of neck compression
AI-generated summary
Rebecca Poke, a 29-year-old woman with borderline personality disorder, died by suicide while an inpatient in Ward E of Casey Hospital on 2 September 2015. She had been admitted following a paracetamol overdose and was on 15-minute nursing observations. Despite appropriate psychiatric care, comprehensive risk assessment, and multi-disciplinary planning, she accessed a D-shaped door handle in a visitor's toilet and hanged herself using her pyjamas. The coroner found the audit tool used to identify ligature points was ineffective, and the door handle (1-2 metres high, in an unsupervised area, with an internal lock) should have been identified and removed. The nursing care, risk management, discharge planning, and clinical decision-making were appropriate. The preventable element was the presence of an accessible ligature point that proper environmental safety auditing should have identified.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
40y · Male·Unascertained
Nathan James Taylor, aged 40, died in Port Lincoln Prison on 24 March 2022 while in custody pending trial on witness interference charges. He had significant medical history including infective endocarditis with tricuspi…
36y · Male·Drowning
Gary Dale Sargeant, a 36-year-old Royal Australian Air Force member, died by drowning after absconding from Edinburgh Health Centre during an acute mental health crisis. Critical clinical failures included: a clinical ps…
59y · Male·Multiple injuries
Martin Carl Quiterio, a 59-year-old man with longstanding schizophrenia and suspected autism spectrum disorder, died on 3 January 2024 when he jumped from the 14th floor of a car park in West Perth. He had been discharge…
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 —