Deceased
Kira Shae James
Demographics
21y, female
Coroner
Coroner Leveasque Peterson
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. Report an inaccuracy.
Specialties
Error types
Clinical conditions
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40y · Female·hypoxic ischaemic encephalopathy due to ligature compression of the neck
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