Finding into death of Michelle Williams
Deceased
Michelle Williams
Demographics
46y, female
Date of death
2016-08-29
Finding date
2020-12-18
Cause of death
Hypoxic brain injury in the setting of plastic bag asphyxia
AI-generated summary
Michelle Williams, a 46-year-old woman with longstanding schizophrenia and depression, died from hypoxic brain injury due to plastic bag asphyxia while an involuntary inpatient in a psychiatric unit. On 27 August 2016, during a period of heightened agitation about being unable to leave the ward, she had access to a plastic bag from a bin and was found unresponsive with the bag over her head. Critical failures included: insufficient staffing coverage led to a missed hourly observation at 12.00pm when two LDU nurses were assisting in the HDU; failure to perform a required formal risk assessment despite observable deterioration in her mental state that morning; and inadequate environmental controls allowing plastic bags in the inpatient unit. While PRN medication was not administered during her morning agitation, evidence suggests this would not have prevented her death. The coroner found these failures directly contributed to her death and commended subsequent systemic improvements in staffing protocols, risk assessment procedures, and environmental safety measures.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- Failure to ensure sufficient staffing coverage in Low Dependency Unit between 11.50am and 12.20pm on 27 August 2016
- Failure to perform hourly observation at 12.00pm on 27 August 2016
- Failure to conduct formal risk assessment following significant deterioration in mental state on morning of 27 August 2016
- Inadequate environmental controls allowing access to plastic bag within inpatient unit
- Failure to investigate source of plastic bag found on patient on 12 August 2016
- Failure to notify family of incidents on 12 August and 25 August 2016 and of transfers to/from High Dependency Unit
Coroner's recommendations
- Bendigo Health should formalise the inclusion of plastic bags in their regular ligature audit
- Bendigo Health should amend their Searches of Patients and Visitors in Psychiatry Inpatient and Residential Units protocol to include that when a patient is found with a prohibited item, all reasonable efforts are made to identify how the patient accessed the item, steps be taken to prevent future access to such items in similar circumstances, and that such steps be documented in the patient's medical record
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