Inquest into the Death of Kirsty Anne Slater
Deceased
Kirsty Anne Slater
Demographics
24y, female
Date of death
2006-04-19
Finding date
2008-07-07
Cause of death
Ligature compression injury to the neck (hanging)
AI-generated summary
Kirsty Anne Slater, a 24-year-old woman with extensive mental illness and substance abuse history, was found hanging from a tree in a park on 19 April 2006, nine days after absconding from Fremantle Hospital's Alma Street Clinic where she was an involuntary psychiatric patient. She had been admitted on 3 April 2006 with psychosis secondary to substance abuse. On 10 April, despite a history of two previous abscondings, she was granted escorted ground access with a single nurse and fled through the hospital. The coroner made an open finding as to how death arose, noting insufficient evidence of suicidality. Key deficiencies identified: nursing staff unaware of prior absconding history; no alert system for absconding in hospital records; confusing mental health policy regarding management of absconding involuntary patients; and lack of clarity about legal status after 72 hours absence.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- Absconding from involuntary psychiatric admission
- History of polysubstance abuse with active drug use after absconding
- Psychosis secondary to substance abuse
- Poor medication compliance
- Escorted ground access granted despite prior absconding history
- Nursing staff unaware of previous absconding incidents
Coroner's recommendations
- Hospitals in Western Australia providing mental health services should ensure that their files, both paper and electronic, contain an alert section which records occasions on which an involuntary patient has absconded from hospital and the context in which the absconding took place.
- The South Metropolitan Mental Health Services Policies and Procedures Manual relating to missing or suspected missing patients should be amended by deleting the section headed 'Involuntary Patient – not considered to be a/at risk and location known.'
Full text
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