Deceased
Veronika Anastasia Kouros
Demographics
31y, female
Coroner
Coroner Audrey Jamieson
Date of death
2018-03-19
Finding date
2023-06-22
Cause of death
Plastic bag asphyxia
AI-generated summary
31-year-old Veronika Kouros, a voluntary inpatient at Northern Psychiatry Unit with bipolar affective disorder, obsessive-compulsive disorder, and depression, died by plastic bag asphyxia on 19 March 2018. Despite hospital procedures mandating removal of plastic bags on admission, she obtained a plastic bag and placed it over her head between 6:00-7:00 AM. She had been assessed as not presenting acute suicidal risk the previous evening and was observed asleep at 6:00 AM. The coroner found the death preventable, concluding that procedures in place failed to prevent her access to this high-risk item. Key clinical lessons include: (1) eliminating access to means of self-harm in psychiatric inpatient units is critical suicide prevention; (2) inconsistent risk assessment approaches to 'benign' personal items are problematic; (3) the emphasis on 'least restrictive means' cannot override safety in high-risk settings; (4) defensive language dismissing removal of dangerous items lacks empirical support and is inappropriate when system failures occur.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
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