Inquest into the Death of Carole LIVESEY
Deceased
Carole LIVESEY
Demographics
54y, female
Coroner
Deputy State Coroner Linton
Date of death
2017-10-03
Finding date
2022-01-25
Cause of death
unascertained
AI-generated summary
Carole Livesey, a 54-year-old woman with severe anorexia nervosa and major depression, absconded from Rockingham Hospital psychiatric unit on 3 October 2017 during an escorted walk in hospital grounds. She had been an involuntary patient admitted on 7 September 2017 following multiple suicide attempts. Though found wet and distressed (suggesting attempted drowning) by the Salvation Army, police failed to attend within the critical timeframe due to resource constraints and she disappeared. The coroner found she likely died around the time of absconding from suicide. Key clinical lessons: (1) Consulted psychiatrist, not registrar alone, should approve involuntary patient leave; (2) Progress risk assessments must be completed before leave; (3) Knowledge of patient's prior absconding history should inform risk assessment; (4) Eating disorder services require multidisciplinary coordination from admission; (5) Family should be consulted for relevant clinical information when assessing leave decisions; (6) No psychologist input despite availability; inadequate eating disorder specialty care.
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Specialties
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- failure to conduct progress risk assessment before granting leave
- absence of consultant psychiatrist approval for leave (registrar-approved only)
- lack of formal documentation of leave approval
- non-consultation with covering psychiatrist (Dr Ojo or Dr Thomas)
- inadequate coordination of multidisciplinary eating disorder service
- absence of psychology input despite availability
- delayed knowledge of patient's suicidal communications with other patients
- family not consulted regarding leave decision despite relevant clinical information
- knowledge of prior absconding incident (May 2017) not documented in current admission
- police resource constraints and delayed response to Salvation Army location
- patient's desperation from ward confinement and forced weight gain against will
- patient's determination to escape after nasogastric tube insertion and activity restrictions
Coroner's recommendations
- Implement standardised phrases for leave approval in patient records
- Introduce new form for all leave of absence approvals requiring consultant psychiatrist signature and approval
- Review leave approval every 48 hours
- Establish mandatory progress risk assessment completion before granting leave to involuntary patients
- Ensure consultant psychiatrist (not registrar alone) approves all leave for involuntary mental health patients
- Implement multidisciplinary team review process for eating disorder patients within 72 hours of admission (dietician, nurses, allied health, consultant oversight)
- Ensure dietician involvement from day one of admission for eating disorder patients
- Improve coordination of eating disorder service across hospital (medical, psychiatric, psychology, dietetics)
- Ensure psychology services available as part of multidisciplinary approach for eating disorder inpatients
- Consult family members when assessing risk for leave decisions, particularly when relevant clinical information exists
- Review patient history including prior absconding incidents when conducting risk assessments
- Improve communication between hospital and police regarding risk level of mental health absconders
- Coordinate with WA Police to revise absconder forms and communication protocols to better convey risk level
- Consider revising police priority tasking for high-risk mental health absconders to allow more rapid response
Full text
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