Finding into death of Ruby-Lee Gold
Deceased
Ruby-Lee Gold
Demographics
28y, female
Date of death
2021-10-28
Finding date
2023-10-05
Cause of death
Multiple injuries sustained in a fall from height
AI-generated summary
Ruby-Lee Gold, a 28-year-old with schizoaffective disorder and polysubstance abuse, died from multiple injuries sustained falling from an overpass after absconding from Sunshine Hospital's emergency department. She was released from custody on an Inpatient Assessment Order (IAO) and should have been transferred to Northern Hospital's mental health inpatient unit, but was diverted to Sunshine Hospital's ED due to Victoria Police resourcing constraints. She remained in the busy, non-therapeutic ED environment for nearly 24 hours awaiting transfer to an inpatient facility. While staff were attending to an unrelated Code Grey incident, she left the ED unobserved and subsequently died. The coroner identified a systemic failure in the transport process for persons released from custody on mental health orders. Key clinical lesson: persons with acute mental illness should not remain in overcrowded, high-stimulus ED environments longer than necessary. The coroner recommended Corrections Victoria assume transport responsibilities with Forensicare clinical support to enable timely transfer to appropriate inpatient mental health facilities.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Contributing factors
- Transfer to Sunshine Hospital ED rather than planned Northern Hospital inpatient facility due to Victoria Police resourcing constraints
- Nearly 24-hour stay in busy, non-therapeutic emergency department environment
- Overcrowding in mental health inpatient services (NWMH 'in extremis' with ~20 persons awaiting acute mental health beds)
- Staff attending to Code Grey incident with another patient when Ruby absconded
- Systemic delays in transport of persons released from custody on assessment orders
- Ruby's history of impulsive and unpredictable behaviour
- COVID-19 pandemic restrictions requiring testing before inpatient transfer
Coroner's recommendations
- The Department of Justice and Community Safety and the Department of Health implement a system to enable Corrections Victoria (or a suitable contractor such as G4S) to undertake the role of transporting persons released from custody on an assessment order under the Mental Health and Wellbeing Act 2022 to a designated mental health service
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