Inquest into the Death of Olivia ("Peta") Dawson

Contributing factors

• assessment of moderate rather than high suicide risk
• no formal suicide risk assessment form completed
• no 'no suicide contract' obtained on this admission
• no search of patient's belongings for potential ligature materials
• assignment to a room not optimally visible from nurse's station
• brief gap in nursing supervision (7 minutes elapsed between last observation and discovery)
• only one nurse on duty in ward during critical period
• nurse on break away from ward between 7.45pm and 8pm
• curtain rail available as ligature point
• patient admitted with shoelace from home (likely)
• hospital not authorized under Mental Health Act to detain patients in secure room
• no mental health nurse on duty at time of admission

Coroner's recommendations

1. Hospital staff, with patient consent, should search patients' belongings and remove items that could be used for self-harm or suicide when there is any perceptible risk of self-harm or suicide.
2. A room should be designated as an observation room for patients at risk of self-harm, preferably located near the nurse's station, constructed with safety glass windows to maintain visibility, and kept free of hazardous equipment or items that could be used for self-harm or as aids to suicide.
3. The hospital policy 'Identification of Patients at Risk of Self Harm' should be improved and updated to require clinicians to thoroughly document risk factors in the patient's medical record including current mental state, stated intent, history of suicide attempts, availability of means, and other relevant factors.
4. The hospital policy should include reference to removal of harmful agents, provision of an observation room, one-to-one nurse specialling, and possible transfer to mental health units in Perth.