Coronial
VIChospital

Finding into death of Ms NXA

Deceased

Ms NXA

Demographics

54y, female

Date of death

2021-08-11

Finding date

2025

Cause of death

neck compression secondary to hanging

AI-generated summary

Ms NXA, a 54-year-old woman with complex mental health conditions including depression, CPTSD, and anxiety, presented to hospital after a suicide attempt by overdose on 9 August 2021. She was experiencing severe tinnitus-related distress alongside multiple psychosocial stressors. Despite expressing clear suicidal ideation and a specific plan to end her life upon discharge, she was discharged on 10 August 2021 with minimal safety planning, no mental health treatment arranged, and without a local GP. The clinicians adopted a narrow formulation attributing her suicidality solely to tinnitus and deemed psychiatric admission unnecessary. She died by hanging the following day. The coroner found multiple missed opportunities: inadequate holistic risk assessment, failure to recognise the expressed suicide plan as a new change requiring escalation, lack of investigation into her tinnitus, and extremely poor discharge planning that was disproportionate to her demonstrated risk.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

emergency medicinepsychiatrygeneral practice

Error types

diagnosticcommunicationsystemdelay

Drugs involved

diazepamthiamineescitalopramcitalopramolanzapinemeloxicamatenololirbesartanpromethazineparacetamol

Clinical conditions

depressioncomplex post-traumatic stress disorder (cptsd)panic disordergeneralised anxiety disorderanxietyalcohol use disordertinnitussuicidal ideationinsomnia

Contributing factors

  • untreated tinnitus causing severe distress
  • complex mental health history including depression, CPTSD, panic disorder, anxiety
  • multiple psychosocial stressors including family legal disputes, family estrangement, social isolation
  • alcohol use disorder
  • inadequate risk assessment focusing narrowly on tinnitus rather than holistic formulation
  • failure to recognise suicide plan as new clinical change requiring escalation
  • inadequate safety and discharge planning
  • lack of follow-up mental health arrangements
  • absence of accessible GP in Victoria
  • lack of investigation into underlying causes of tinnitus
  • patient's father hospitalised, reducing social support

Coroner's recommendations

  1. That the Royal Australian and New Zealand College of Psychiatrists promote awareness to its members of the significant psychosocial impacts of tinnitus and tinnitus-related distress, including the risk of suicide
Full text
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