Finding into death of C L
Deceased
CL
Demographics
53y, male
Date of death
2023-09-13
Finding date
2024-12-16
Cause of death
Cervical spine distraction and hanging
AI-generated summary
A 53-year-old man with chronic treatment-resistant depression and chronic suicidality was admitted to Northern Hospital following a serious suicide attempt. He was assessed as high-risk but discharged after 19 days with referral to community mental health services. He died by suicide approximately 6 hours after discharge. The coroner found the general care was reasonable but identified significant deficiencies in discharge planning: PARC step-down admission was inappropriately unavailable due to accommodation funding restrictions; ACIS referral was not arranged with sufficient advance notice for meaningful pre-discharge engagement; accommodation provider assessment was not conducted; and no firm follow-up appointment was secured within 24 hours. The coroner emphasised that while high suicide risk alone should not prevent community discharge, exceptionally careful discharge planning is required. The hospital's review process was inadequate and should have been conducted as a formal Sentinel Event review.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- Treatment-resistant depression
- Chronic suicidality
- Inadequate discharge planning process
- PARC step-down admission unavailable due to accommodation funding restrictions
- ACIS referral not arranged with sufficient advance notice
- Patient did not visit accommodation prior to discharge
- Lack of firm follow-up appointment secured before discharge
- Recent serious suicide attempt (vehicle collision 12 August 2023)
- Significant psychosocial stressors including relationship breakdown, business collapse, debt, family separation
- Poor social support and limited protective factors
- Borderline Personality Disorder
- Patient impulsive and emotionally labile
- Limited family involvement in discharge planning despite their concerns
- Discharge occurred within hours of change from compulsory to voluntary treatment status
Coroner's recommendations
- Northern Health review its accommodation support services to ensure availability for allocation towards accommodation required subsequent to an intervening step-down admission to PARC
- Northern Health review their discharge process for mental health in-patients and associated policies and procedures to ensure consistency with the Chief Psychiatrist's guideline: Transfer of care and shared care and the Department of Health's guideline: Transfer of care from acute inpatient services
- Safer Care Victoria review Category 11 (Subcategory 4) of the Victoria sentinel event guide (Version 2) to consider explicit inclusion of suicide deaths that occur within 24 hours of discharge from an inpatient facility
- Northern Health review their policies and procedures in relation to the reporting of Sentinel Events to ensure they are consistent with Safer Care Victoria's Victoria sentinel event guide (Version 2)
- Northern Health review their policies and procedures in relation to their reporting obligations in response to patients who have died by suicide within 24 hours of discharge to ensure they are consistent with Safer Care Victoria's Adverse Patient Safety Event Policy
Full text
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