Inquest into the Death of Aileen Helen QUARTERMAINE
Deceased
Aileen Helen QUARTERMAINE
Demographics
60y, female
Date of death
2014-07-26
Finding date
2018-03-22
Cause of death
effects of fire in a woman with alcohol effect
AI-generated summary
A 60-year-old woman with chronic paranoid schizophrenia died in a domestic fire on 26 July 2014. The day before, her son sought help from police and mental health services after noticing signs of mental health deterioration. Police attended but failed to identify the patient as the subject of the call, did not obtain details, and did not pursue further enquiries despite seeing/hearing a woman at the address. The mental health service received limited information from two phone calls and did not escalate concerns. The coroner found missed communication opportunities that may have enabled appropriate assessment and treatment. Both agencies subsequently implemented improved procedures for information gathering, escalation, and coordination between police and mental health services in regional areas.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- mental health deterioration precipitated by alcohol use
- patient intoxication at time of death
- failure of police to adequately assess the situation
- failure of police to identify the patient as subject of the call
- communication failures between police and mental health service
- inadequate information obtained from initial phone call to mental health
- lack of crisis management plan for high-risk patient
- limited information shared during staff handover when regular case manager was on leave
Full text
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