Finding into death of Paul Peterson
Deceased
Paul Peterson
Demographics
54y, male
Coroner
State Coroner Judge John Cain
Date of death
2014-07-01
Finding date
2020-03-17
Cause of death
Neck compression (hanging)
AI-generated summary
Paul Peterson, 54, died by hanging after leaving a private psychiatric hospital on unapproved leave while on close observations. He was admitted with major depression, suicidal ideation, and opioid dependence. On 1 July 2014, despite being on hourly observations and deteriorating mental state that evening (agitation, tremors after ceasing medication for ECT), he was allowed accompanied leave with his partner. The hospital's therapeutic leave policy was unclear and incompletely followed. Dr W. was unfamiliar with written procedures. Critically, leave was not formally approved that day despite policy requirements for pre-leave risk assessment before each specific instance. The patient's clinical deterioration that evening—evident agitation and tremors—should have triggered refusal of leave. No formal handover to nursing staff occurred on return. Systemic failures included lack of familiarity with policies, unclear written procedures, reliance on undocumented practices, and failure to recognise and act on acute clinical deterioration as a contraindication to leave.
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Specialties
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- Major depressive disorder with melancholic features
- Opioid dependence and misuse
- Acute medication withdrawal (diazepam cessation for ECT)
- Clinical deterioration with agitation and tremors not acted upon
- Leave granted without formal pre-leave risk assessment despite policy requirements
- Lack of familiarity by treating psychiatrist with written therapeutic leave procedures
- Unclear and incomplete written policies and procedures
- Reliance on undocumented and inaccessible unwritten practices
- Failure to discourage leave when patient's mental state deteriorated
- Inadequate communication of leave responsibilities to carer
- No formal handover of patient to nursing staff on return from leave
Coroner's recommendations
- Conduct a comprehensive review of the operation of and compliance with the January 2020 Therapeutic Leave Policy and Therapeutic Leave Procedure by an independent person, to be completed no later than September 2021
- Consider developing an e-learning or online training module for staff and consultants directed at obligations and compliance with the Therapeutic Leave Policy and Procedure
Full text
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