Finding into death of Mr CLX
Demographics
85y, male
Date of death
2021-08-24
Finding date
2022-08-01
Cause of death
Incised wounds to the wrist
AI-generated summary
An 85-year-old man with myelodysplasia and severe hip pain from an ischiorectal abscess died from incised wrist wounds sustained in a nursing home while in palliative care. He had expressed wishes to die, discussed euthanasia, and resisted resuscitation efforts. The coroner found care was appropriate given his circumstances. However, the case highlights gaps in suicide risk assessment and mental health support for palliative and aged care patients. Clinical lessons include: recognising suicide risk in older patients with chronic pain and functional decline; ensuring adequate psychosocial assessment alongside pain management; maintaining vigilance despite palliative care focus; and considering environmental factors (isolation from family due to COVID restrictions) contributing to hopelessness. The coroner made recommendations for improved suicide risk training, mental health service access pathways, and psychosocial support protocols in aged care settings.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- myelodysplasia and anaemia
- severe uncontrolled hip pain
- ischiorectal abscess
- COVID-19 restrictions limiting family visits
- social isolation in nursing home
- feelings of hopelessness and desire to die
- inadequate suicide risk assessment procedures
- lack of psychosocial support in palliative care setting
Coroner's recommendations
- Cohuna District Hospital to provide psychosocial supports for residents in aged care and palliative care programs
- Strengthen staff training in assessment of suicide risk for aged care and palliative patients
- Develop a flowchart outlining access to mental health services for residents in aged care and palliative programs
- Update the suicide risk procedure for aged care and palliative programs
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