Deceased
Elizabeth Anne Palmer
Demographics
39y, female
Coroner
Coroner Phillip Byrne
Date of death
2016-05-13
Finding date
2018-03-13
Cause of death
Hypovolaemic shock due to incised injury to the wrist
AI-generated summary
A 39-year-old woman with a history of mental health issues and previous suicide attempts was admitted to a high-dependency psychiatric unit following a suicide attempt involving razor blades and medications. She was placed on a Temporary Treatment Order and her belongings were searched on admission. A Kindle device was not thoroughly examined—the cover was not removed to check for concealed dangerous items. The following day, her husband informed her he would not reconcile their marriage. Shortly after, she accessed a razor blade she had secreted in the Kindle cover, used it to self-harm fatally, and died from hypovolaemic shock. The coroner found the search was inadequate given her high risk of self-harm and the High Dependency Unit context. The hospital initially resisted but later conceded the Kindle should have been removed from its cover. This case highlights the importance of thorough searches of all items, including electronic devices, in high-risk psychiatric inpatients.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
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