Demographics
46y, female
Date of death
2016-01-28
Finding date
2020-05-27
Cause of death
Hanging
AI-generated summary
A 46-year-old woman with a history of depression, anxiety, and alcohol dependence died by hanging. She was transported to Box Hill Hospital on 27 January 2016 under Mental Health Act section 351 following suicidal ideation and overdose of prescribed medications with alcohol (BAC 0.179). Eastern Health correctly assessed she didn't meet criteria for involuntary admission and planned comprehensive assessment once sobered. However, miscommunication between ED staff led to her discharge—a nurse granted permission to leave for a cigarette believing a doctor had approved this, when no such approval existed. Nicotine withdrawal, untreated throughout her admission, contributed to repeated requests to leave. After self-discharge, a mental health clinician's telephone assessment was deemed adequate, but coronal findings suggest face-to-face follow-up by crisis team within 24-48 hours would have been reasonable given intoxication and poor engagement. Police interactions prior to death were appropriate, though a suicide note left at home on 28 January was briefly observed but not recognized as significant.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
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