Finding into death of Kira Shae James
Deceased
Kira Shae James
Demographics
21y, female
Date of death
2017-11-05
Finding date
2022-12-15
Cause of death
Neck compression
AI-generated summary
Kira Shae James, a 21-year-old with psychosis, borderline personality disorder, and eating disorder, died by ligature at Thomas Embling Hospital while an involuntary inpatient under Mental Health Act orders. She had a lengthy history of self-harm (39 documented episodes during admission) and complex psychiatric needs. On the morning of her death, despite being assessed as low-risk and appearing settled, she was not directly sighted during a mandatory hourly security check at 8:56am—staff heard noises and marked her present without visual confirmation. She was found deceased at 9:58am with ligatures around her neck. The Root Cause Analysis identified failure to follow patient count procedures, lack of escalation when the check could not be completed properly, inconsistent staff training in personality disorder and eating disorders, and distraction as contributing factors. Key lessons: strict adherence to observation protocols is essential even when patients appear stable; hourly checks must include direct sighting; when staff cannot complete checks, escalation to senior staff is mandatory, not optional.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- Failure to conduct direct visual sighting during hourly patient count procedure
- Staff marked patient present without visual confirmation
- No escalation to senior staff when hourly check could not be properly completed
- Staff inattention and distraction
- Lack of centrally accessible care plans
- Varied levels of staff knowledge and skills in managing borderline personality disorder and eating disorders
- Patient's chronic self-harm and suicidal ideation
- Patient's fixation with weight loss not adequately addressed in management plan
- Challenge of managing complex acute and sub-acute patient mixture
Coroner's recommendations
- That Forensicare amend its policy on Patient Counts to include an escalation process that is applicable in circumstances where the clinician allocated to conduct the count is unable to complete it within the required timeframe. This escalation process should enable the task to be reallocated to an available clinician.
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —