Finding into death of Paige Dent
Deceased
Paige Dent
Demographics
25y, female
Date of death
2018-10-06
Finding date
2022-12-22
Cause of death
Injuries sustained in a single vehicle motor vehicle incident in which Ms Dent was the driver
AI-generated summary
Paige Dent, 25, died in a single-vehicle motor accident after absconding from hospital on 6 October 2018. She had a 19-year history of psychiatric admissions for schizophrenia, borderline personality disorder, and substance use disorder, with acquired brain injury. While under an Inpatient Treatment Order at Dandenong Hospital's Secure Extended Care Unit, she was in the discharge planning phase and approved for leave. She absconded from the ED on 5 October 2018 while awaiting psychiatric review and bed placement. She was not admitted to a secure ward but remained in the ED with a continuous patient observer. The coroner found that although no HDU bed was available and the ED staff's actions were reasonable, documentation of bed-search efforts, including out-of-area options, was inadequate. The clinical lessons include: ensure comprehensive and documented searches for appropriate beds across regional networks, position patients at high absconding risk away from exits, provide active treatment in ED to reduce agitation, and follow escalation procedures when beds are unavailable.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- Absconding from emergency department while subject to Inpatient Treatment Order
- Inadequate documentation and search for out-of-area mental health beds
- Lack of secure accommodation in emergency department
- Methamphetamine and cannabis use prior to driving
- Acquired brain injury with behavioural absconding risk
- Chronic substance use disorder
- Homelessness and lack of appropriate post-discharge accommodation
Coroner's recommendations
- Monash Health should formulate a policy for formally documenting enquiries in relation to accessing high and low dependency beds for patients subject to an Inpatient Treatment Order who present to the emergency department, following a stepped process: (i) provide active treatment in ED to reduce frustration and agitation; (ii) source an in-area high dependency unit bed; (iii) if unavailable, source an out-of-area high dependency unit bed; (iv) if unavailable, source an in-area low dependency unit bed; (v) if unavailable, source an out-of-area low dependency unit bed; (vi) if unavailable, situate the patient in the ED with a continuous patient observer, positioned furthest away from exits.
Full text
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