Deceased
Michelle Hughes
Demographics
53y, female
Coroner
Coroner Darren Bracken
Date of death
2017-01-26
Finding date
2022-02-11
Cause of death
Ligature strangulation
AI-generated summary
Michelle Hughes, a 53-year-old woman serving her first prison sentence for assault committed during drug-induced psychosis, died by ligature strangulation in her cell at Dame Phyllis Frost Centre Women's Prison on 26 January 2017. She had a complex psychiatric history including bipolar disorder, borderline personality disorder, and delusional disorder, with multiple prior episodes of serious self-harm. On 25 January 2017, Registered Nurse Pare conducted an 'at risk' assessment following observation of bruising around her neck. The assessment was conducted through a cell door window, with limited direct observation. Pare concluded Ms Hughes was not at immediate risk and maintained her S4 rating (lowest risk category). The Coroner found the assessment was 'a background circumstance' rather than a cause of death, though noted Pare probably should have rated her S3 given her history. Critical clinical lessons include: (1) at-risk assessments are ephemeral and may be manipulated by patients; (2) single-point-in-time risk assessments have limited predictive value for suicide risk that may change rapidly; (3) assessment through a cell door window severely limited clinical evaluation; (4) hourly observations by untrained officers checking only for signs of life are ineffective prevention strategies. The coroner recommended investigation of continuous vital signs monitoring for high-risk prisoners.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
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