Finding into death of Lorraine Joy Wight
Deceased
Lorraine Joy Wight
Demographics
77y, female
Date of death
2023-09-12
Finding date
2025-05-21
Cause of death
Airways obstruction by tissue paper
AI-generated summary
A 77-year-old woman with depression, anxiety, and chronic pain died from airway obstruction by tissue paper at an aged care facility. She had expressed suicidal ideation, attempted self-harm, and was found with tissues in her mouth on two occasions before her fatal event. The internal investigation identified critical failures: absence of a deteriorating mental health policy, multiple communication breakdowns (missed handovers, no incident documentation in standard systems), and failure to escalate to mental health services despite clear warning signs. A hospital admission or formal mental health review was required but not obtained. While staff implemented some risk mitigation measures, these proved inadequate. The coroner noted the facility's post-incident corrective measures were appropriate, addressing policy gaps and staff training in mental health recognition and escalation protocols.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- Absence of policy for deteriorating mental health
- Multiple points of communication failure
- No Riskman entry for suicide attempts
- Items not captured in handover
- Absence of resident risk in management stand-up meeting notes
- Failure to escalate to mental health services
- Limited access to mental health services
- Inadequate risk mitigation measures
- Lack of clear escalation process
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