Finding into death of LKV LKV

Contributing factors

• Low risk assessment despite high-risk presentation
• Minimal engagement with clinical staff not reflected in risk rating
• Lack of documented mental state examinations
• Non-compliance with observation policy during critical period
• Accessible ligature point on bathroom door
• Insufficient therapeutic engagement during observations
• Delay in psychological referral response
• Business and financial stressors leading to depression
• Recent suicidal ideation and statements about methods
• Isolation and withdrawn behaviour not escalating risk assessment

Coroner's recommendations

1. Develop process to conduct risk assessment when patient displays resistance to 1:1 therapy and/or treatment, documented in clinical record and communicated to health care team
2. Adjust bathroom doors so they swing in either direction under load, secured by piano hinges, cut down from door frame and at angle
3. Review Risk Assessment and Visual Observations policy to include medication times as concern area and consider reducing maximum allowable interval between observations
4. Alter Visual Observation form to require nurse to confirm patient is alive at time of observation
5. Retain copy of clinical handover sheet from each shift for minimum of 12 months
6. Complete documentation contemporaneously or in summary toward end of shift
7. Document Items of Risk check results in medical record, including items located and actions taken
8. Implement visual observation policy requiring engagement (or attempted engagement) with patients at time of observation, with outcomes recorded on observation chart
9. Ensure reciprocity between observation and assessment in context of relationship between engagement and risk assessment