Coronial
WAmental health

Inquest into the Death of Robert David Abbott

Deceased

Robert David Abbott

Demographics

67y, male

Date of death

2003-12-19

Finding date

2005-09-23

Cause of death

Ligature Compression of the Neck (Hanging)

AI-generated summary

Robert David Abbott, aged 67, died by hanging in the secure ward of Joondalup Health Campus on 19 December 2003. He had a long history of depression exacerbated by chronic pain from a 2000 motor vehicle accident, and required multiple psychiatric admissions. On 18 December 2003, he disclosed to nursing staff that he had attempted to prepare a noose using his dressing gown cord the previous night, stating he was unable to guarantee his safety. He was appropriately transferred to the secure ward and the cord was removed and locked in storage with his suitcase. However, at some point during the night shift, a staff member with access to the secure area returned the suitcase containing the cord to his room. The coroner found this was an error that contributed to his death. The coroner could not determine whether this was due to genuine mistake, miscommunication, or misjudgement of the deceased's status. The coroner recommended implementation of written policies for tracking patient property movement, which was subsequently done.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

psychiatrygeneral medicineneurology

Error types

proceduralsystem

Drugs involved

venlafaxinequetiapinemorphinediazepam

Clinical conditions

major depressive episodechronic pain syndromemigrainesuicidal ideationauditory hallucinations

Procedures

electroconvulsive therapy

Contributing factors

  • Return of suitcase containing dressing gown cord to secure ward patient
  • Chronic pain from motor vehicle accident in 2000
  • Major depressive episode
  • Suicidal ideation and expressed plan to use ligature
  • Lack of written policies for management of patient property in secure ward
  • Unclear communication regarding dangerous items in patient belongings

Coroner's recommendations

  1. Implementation of written policies and protocols for management of all patient property in secure mental health wards, not just valuable items
  2. Implementation of itemised recording and tracking system for property removed from patients, with requirement for staff to sign property out before return to patient
  3. Requirement for staff member returning property to consciously consider appropriateness of return given patient's clinical circumstances and suicide risk factors
  4. Enhanced training for staff on suicide risk assessment and recognition of potentially dangerous items, including items stored with patient belongings in secure wards
Full text
Official source Archived copy

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