Finding into death of Caterina Fratto
Deceased
Caterina Fratto
Demographics
45y, female
Date of death
2015-03-07
Finding date
2019-07-30
Cause of death
Hanging
AI-generated summary
A 45-year-old woman with bipolar affective disorder, borderline personality disorder, anorexia nervosa and depression died by hanging. She had chronic suicidal ideation and was managed in the community by a mental health team despite expressing active suicidal thoughts in the days before her death, including a recent overdose attempt. The clinical management was considered appropriate given her capacity to refuse admission and the team's view that involuntary treatment was unlikely to help. However, the coroner identified significant deficiencies in documentation: no formal risk assessment was completed after 12 December 2014 despite clinical deterioration, and there was no documented evidence of a critical clinical review meeting on 6 March 2015 where serious concerns were discussed. The coroner emphasised that proper documentation of risk assessments and clinical decisions is essential for patient safety in suicide prevention.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- Chronic suicidal ideation
- Treatment-resistant depression
- Recent overdose attempt (1 March 2015)
- Deteriorating mental state in context of social stressors and relationship difficulties
- Inadequate documentation of risk assessments and clinical decision-making
- Absence of formal risk assessment between 12 December 2014 and date of death
Coroner's recommendations
- Mental health services should ensure that their policies and procedures reflect Department of Health guidelines on working with suicidal persons, specifically regarding the need for regular documented risk assessments
- All clinicians should be cognizant of the importance of adhering to mental health policies and procedures regarding careful and detailed documentation
- Clinical decisions should be based on documented risks and evidence of consultation that supports the treatment plan
- Mental health services should implement systematic documentation of risk assessments, particularly in active crisis-oriented assessment and management of suicidal persons
Full text
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