Deceased
Annette SILVER
Demographics
47y, female
Date of death
2015-01-02
Finding date
2017-06-22
Cause of death
Multiple injuries from being struck by a train
AI-generated summary
A 47-year-old woman with major depressive disorder and anxiety died by suicide while an involuntary psychiatric inpatient. She had attempted suicide in November 2014 and was admitted to Bentley Hospital for psychiatric treatment. Despite appropriate medication management, psychotherapy, and regular clinical review, she absconded from the hospital on 2 January 2015 and placed herself in front of a train. The coroner found treatment was reasonable and generally appropriate. Key clinical lessons include: the difficulty of predicting suicide in severe depression, the balance between restrictive and therapeutic care in secure wards, the importance of continuity in psychological therapy, and the need for adequate mental health resources to support clinical decision-making around bed allocation and staffing levels.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
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