Deceased
Valerie Lucy Jones
Demographics
86y, female
Date of death
2020-06-18
Finding date
2021-08-12
Cause of death
Plastic bag asphyxia
AI-generated summary
An 86-year-old woman with delirium, depression, and multiple cardiac comorbidities died by asphyxiation with a plastic bag while in a transitional care facility. She had expressed wishes to die, references to suicide, and demonstrated concerning behaviour (suffocating her pet canary, collecting plastic bags). The mental health assessment concluded her suicidal statements were due to delirium rather than major psychiatric illness, and ongoing mental health input was not recommended. The coroner found that despite references to suicide and death, no formal welfare-checking protocol was implemented. The hospital's root cause analysis identified inadequate suicide risk assessment procedures, limited staff knowledge, poor communication between clinical teams, and insufficient psychosocial supports as contributing factors. The coroner noted that while her state of mind at time of death could not be determined with certainty, a regular welfare-checking process should have been in place.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
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