Inquest into the Death of Nualla Christine REILLY
Deceased
Nualla Christine REILLY
Demographics
74y, female
Date of death
2017-06-09
Finding date
2020-05-26
Cause of death
Multiple injuries sustained when struck by train
AI-generated summary
A 74-year-old woman with borderline personality disorder, depression, anxiety and type 2 diabetes died by suicide after absconding from Fiona Stanley Hospital Emergency Department. She had been on extended psychiatric admission and transferred to transitional care, where she became acutely suicidal. In the ED, she was appropriately assessed as requiring admission under the Mental Health Act but inadequately supervised. A psychiatric registrar informed an unidentified nurse that she was detained on forms, assuming a nursing special would be automatically allocated. However, this expectation was not communicated to the Assessment Lead. The Assessment Lead, unaware of the detention, incorrectly told another nurse that the patient was being discharged based on a misheard conversation. This nurse then directed the patient to the exit, enabling her departure. The patient was found deceased at a train station approximately 40 minutes later. Key failures included: insufficient communication between psychiatric and nursing staff regarding supervision requirements, lack of a formalised handover when mental health status changed, and delay in notifying police.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- Failure to allocate nursing special despite patient being placed on Mental Health Act forms
- Communication breakdown between psychiatric and nursing staff regarding patient's detention status and supervision requirements
- Assessment Lead unaware that patient had been placed on forms
- Incorrect information provided to Assessment Lead based on overheard conversation regarding discharge plan
- Patient directed to exit by nursing staff who were unaware of detention
- Delay in notifying police of patient's departure from hospital
- Confusion over responsibility for notifying police
- Inadequate supervision window allowing patient to abscond
- Patient's acute escalation of suicidal intent following notification of involuntary transfer to Bentley Hospital
Coroner's recommendations
- Reiterate 'Fiona Stanley Hospital Managing Patients with Mental Health and Psychiatric Conditions in Fiona Stanley Hospital Emergency Department' policy and flow chart to staff
- All patients considered at risk, or under the Mental Health Act, are to be notified to the 'Nurse Area Lead' position to confirm information has been added to EDIS immediately, with changes reflected in policy update
- All referred mental health patients are not to leave the department without the allocated nurse checking EDIS or confirmation with the Mental Health Emergency Department Liaison Service
- Amendment to Nurse Specialling policy to clarify when special observation is required for patients placed on Mental Health Act forms, particularly the necessity of explicit communication between medical and nursing staff
- Implementation of 'review' box in EDIS to flag patients who are not to leave the department without review by the mental health team
- In future clinical incident investigations, ensure all staff involved in an incident are spoken to directly by the investigation panel or that panel members are provided with information from all relevant staff to ensure comprehensive and accurate review
- Ensure staff are informed of their entitlement to obtain independent legal advice and representation in relation to coronial processes
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