Finding into death of Rebecca Victoria Poke
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
Contributing factors
- accessible D-shaped door handle ligature point in visitor's toilet
- door handle 1-2 metres high in unsupervised patient area
- door capable of being locked from inside
- ineffective ligature audit tool and audit application
- chronic suicidal ideation associated with borderline personality disorder
- anxiety regarding discharge and associated responsibilities
Coroner's recommendations
- Department of Health and Human Services work with Area Mental Health Services to develop advice and examples of ligature audit tools that are assessed as being appropriate to the task and effective in meeting their purpose, to improve the effectiveness of required ligature point auditing tools, auditor training and their application in acute care mental health units
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