Deceased
Amanda Alison GILBERT
Demographics
47y, female
Coroner
- Coroner King
Date of death
2010-01-22
Finding date
- 11 April 2014
Cause of death
bronchopneumonia in context of ischaemic heart disease, chronic renal failure, and hypoxic brain injury
AI-generated summary
Amanda Gilbert, aged 47, died from bronchopneumonia with background ischaemic heart disease, chronic renal failure, and hypoxic brain injury from a 1985 hanging attempt. She had been an involuntary patient at Graylands Hospital since 1987. The coroner found that staff provided appropriate care given available resources. Critical deficits existed for her first ten years: she suffered at least 111 assaults from other patients and was in an unsuitable mixed-gender environment. One-to-one nursing care, implemented from 1997 onwards, significantly improved her safety and wellbeing. The coroner emphasised systemic issues: lack of facilities for young people with combined mental illness and brain injury, funding constraints, and inter-agency responsibility gaps between mental health and disability services. While specific clinical care decisions were appropriate, the larger system failed to provide adequate alternatives to psychiatric hospitalisation for her complex needs.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
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