Finding into death of Jackson Desmond David Stawicki
Deceased
Jackson Desmond David Stawicki
Demographics
24y, male
Date of death
2020-09-11
Finding date
2023-07-28
Cause of death
Haemorrhagic shock in the setting of a sharp force injury to the left arm
AI-generated summary
Jackson Stawicki, 24, died from haemorrhagic shock following a sharp force injury to his left arm while intoxicated with multiple illicit substances. He presented to the ED three times within 24 hours (4-5 September 2020) following police apprehension under the Mental Health Act for erratic, aggressive behaviour. Each time, ED and mental health assessments determined he did not meet criteria for compulsory treatment. The coroner found clinical care was reasonable and appropriate at each presentation. However, Barwon Health critically failed to obtain Jackson's valid mobile phone number or updated residential address across all three presentations. This prevented the Child and Youth Triage Team from contacting him as part of the discharge plan. The coroner found Jackson self-inflicted the fatal wound without suicidal intent, likely while significantly judgment-impaired by drugs. The key clinical lesson: obtain and verify current contact details before discharge, especially when community follow-up is essential.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- Failure to obtain valid contact details (mobile phone number and updated address) during three ED presentations
- Inability of community mental health team to contact patient due to missing contact information
- Discharge letter sent to superseded address, likely never received by patient
- Acute intoxication with multiple illicit substances at time of death affecting judgment
- History of depression, substance abuse, self-harm and previous suicide attempts
- Disengagement from services once acute crisis resolved
- Lack of regular GP engagement
Coroner's recommendations
- All staff in clinical settings must ensure patient information, including mobile phone contact details and residential addresses, are up to date, especially when a discharge plan requires proactive contact by a community team for follow-up
- Healthcare staff should be aware of their responsibilities to validate that patient contact details are current and correct
- Health organisations should ensure their policies regarding patient registration and demographic information updates are consistently implemented across all patient presentations
- When a patient is referred for community follow-up as part of a discharge plan, contact details must be verified and the discharge plan reviewed if contact details cannot be verified
Full text
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Source and disclaimer
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