Finding into death of Melissa Gaultier
Deceased
Melissa Gaultier
Demographics
34y, female
Date of death
2017-04-18
Finding date
2022-06-29
Cause of death
Multiple injuries sustained in a motor vehicle incident (pedestrian), in circumstances where the deceased intentionally placed herself into the path of a motor vehicle
AI-generated summary
Melissa Gaultier, 34 years old, was discharged from Latrobe Regional Hospital's psychiatric ward (Flynn Unit) less than 24 hours after admission on 13 April 2017, despite comprehensive warnings from Monash Health that she required psychiatric assessment before any leave. She had bipolar disorder, borderline personality disorder, Type 1 diabetes, and was pregnant (28 weeks). Within hours of discharge, she was readmitted involuntarily. On 17 April 2017, while on approved leave, she absconded from a visitor and was found in circumstances suggesting attempted suicide. She was eventually reported missing; police conducted searches overnight. The next morning she stepped in front of a truck, dying from multiple injuries. The coroner found the hospital's management fraught with shortcomings: failure to observe Melissa for adequate time, disregarding Monash Health's advice, lack of proper risk assessment before leave, and inadequate documentation. The coroner found the death preventable had proper risk management been implemented while she remained in hospital care.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- Premature discharge from psychiatric hospital less than 24 hours after admission
- Failure to observe patient adequately before discharge decision
- Disregard of explicit warnings from referring hospital about need for psychiatric assessment before leave
- Lack of proper risk assessment prior to granting leave on 17 April 2017
- Failure to conduct mental state assessment before leave
- Inadequate documentation of leave entitlements and risk assessments
- Non-compliance with visual observation policy requirements
- Lack of clear processes for staff regarding leave management
- Absence of psychiatric continuity of care during transfer from Monash Health
- Easter period public holiday staffing arrangements affecting continuity of care
- Inadequate handover process - receiving psychiatrist did not become treating clinician
- Failure to escalate care when risk increased on 15 and 17 April 2017
- Possible diabetic ketoacidosis affecting cognitive function at time of death
Coroner's recommendations
- Latrobe Regional Health implement a patient continuity of care transfer admission policy for its inpatient mental health ward, ensuring that appropriately qualified clinician(s)/inpatient consulting psychiatrist receiving handover details from another hospital are rostered and available to continue with that patient's care on admission
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