Finding into death of Mairi Elizabeth Noble

57y · Female·Injuries sustained when struck by a train

Mairi Elizabeth Noble, a 57-year-old woman with a history of alcoholism who achieved sobriety, presented to the Northern Hospital ED twice in the days before her death by suicide. She was discharged prematurely on 21 February 2008 after psychiatric assessment was planned but not properly documented or executed. Critical systemic failures included: communication gaps between ED and ECATT (mental health crisis team), incomplete handover of care plans, inaccessible medical records, and unclear documentation of psychiatric review. An intern discharged her based on incomplete information, unaware that a psychiatry registrar assessment was scheduled. While the coroner found these shortcomings were not the direct cause of death, she identified significant systemic issues including poor referral documentation, ineffective communication systems ('Green Book'), and lack of coordination between services that contributed to suboptimal care during critical presentations.