Finding into death of Thi Ha Do
Deceased
Thi Ha Do
Demographics
42y, female
Coroner
Coroner Simon McGregor
Date of death
2016-08-18
Finding date
2019-05-17
Cause of death
Incised injury to the neck
AI-generated summary
A 42-year-old woman with depression and suicidal ideation died by self-inflicted neck laceration while admitted to a psychiatric inpatient unit. She had been assessed as low risk and placed on 30-minute observations. Clinical management of her depression was reasonable, with appropriate medication adjustments and family engagement. However, critical failures occurred in environmental safety and overnight nursing observations. A visitor brought a knife into the unit at the patient's request, and staff did not detect that she left her bed during night observations—they assumed movement in the bed meant she remained there safely. The coroner identified suboptimal visual observation protocols and lack of risk-linked safety assessment as contributing factors. The hospital subsequently implemented substantial improvements including enhanced risk assessment, mandatory engagement of sleeping patients during rounds, visitor education about dangerous items, and comprehensive staff training on suicide prevention.
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Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- Suboptimal environmental safety—access to a knife brought by visitor
- Inadequate overnight visual observations—staff assumed patient was asleep in bed without engaging to confirm safety
- Lack of risk-linked clinical handover—failure to communicate remarkable improvement in mental state to night shift
- Nursing staff did not complete consolidated risk assessment stickers (CRAM) despite protocol requiring daily completion
- Incomplete engagement with patient during evening and night shifts
- Visitor not adequately informed of prohibition on dangerous items
Coroner's recommendations
- Safer Care Victoria and the Safer Care Victoria Mental Health Clinical Network should work to identify inadequate approaches to excluding dangerous items from psychiatric hospital units and implement improvements, such as those implemented by the Epworth, across the Victorian health system
Full text
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