Inquest into the Death of Frances May COOPER
Deceased
Frances May Cooper
Demographics
48y, female
Date of death
2011-10-30
Finding date
2015-11-30
Cause of death
Head injury
AI-generated summary
Frances May Cooper, a 48-year-old woman with chronic paranoid schizophrenia, died from head injuries after being struck by a train on 30 October 2011 while on unescorted leave from the mental health unit at Kalgoorlie Regional Hospital. She was an involuntary patient under the Mental Health Act 1996. The coroner found the quality of care was objectively unsatisfactory due to lack of formal risk assessments, poor family communication, gaps in community care, a Department of Health smoking prohibition policy forcing patients to leave the ward, and insufficient psychiatric continuity. The decision to allow unescorted leave was ultimately mistaken but not inherently wrong at the time made. Systemic failures rather than individual clinician failures were identified. Since her death, the health service has implemented recommendations including improved case management processes, risk assessment protocols, staff training, and policy changes allowing involuntary patients to smoke in designated areas.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- Involuntary detention status under Mental Health Act 1996
- Decision to allow unescorted leave from mental health unit despite high absconding risk
- Department of Health smoking prohibition policy requiring patients to leave ward to smoke
- Lack of formal risk assessment and documentation processes, reliance on informal assessments
- Lack of continuity and consistency of psychiatric care with multiple treating psychiatrists
- Lack of permanent psychiatrist staffing in rural location
- Gaps in community-based care resulting in undetected mental health deterioration
- Inadequate collaboration with and communication to family members
- Lack of multidisciplinary team approach
- Patient history of non-compliance with medication and repeated absconding
- Uncontrolled cannabis use exacerbating psychotic symptoms
- Small mental health unit without secure facility design
- Lack of clinical leadership in the mental health unit
Coroner's recommendations
- Develop process to transfer case management within the Goldfields Mental Health Service
- Develop improved processes to transfer information with patient including daily communication between Mental Health Inpatient Service and Community Mental Health Service
- Develop processes to ensure case management of patients including follow-up of overdue medication appointments
- Develop process to ensure information from family and carers is documented and included in care planning
- Develop standard process for risk assessment and documentation over the course of treatment
- Develop training for mental health staff, ED staff and hospital coordinator staff in mental state examination as annual core competency
- Develop process for recording leave of absence of involuntary patients from the MHU
- Ensure treatment planning and review includes treating psychiatrist and is consistent with psychiatrist's documented intentions
- Review procedure for discharge of patients from the MHU
- Review Department of Health smoking policy to permit involuntary mental health patients to smoke in designated areas (policy changed January 2013)
- Construct designated smoking area in MHU courtyard
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