Finding into death of Peter James Nolan

75y · Male·Hanging

Peter Nolan, a 75-year-old man with depression, chronic pain, alcohol dependence, and recent suicide attempts, died by hanging in an aged psychiatric mental health unit. He was admitted to Broadmeadows Aged Psychiatric Mental Health Service on 21 September 2013 and placed on 15-minute close observations due to high suicide risk. A blue plastic slip sheet, placed by staff as a temporary curtain to reduce light entering his ground-floor room, was not recognised as a ligature risk despite his known suicide risk and impulsive attempts. On 23 September at 6:45am, nursing staff found him hanging from the slip sheet. Key failings included: lack of systematic ligature risk assessment in his room, no risk analysis of the temporary curtain arrangement, inadequate documentation and actual conduct of the prescribed 15-minute observations (particularly after 6:30am when observations ceased despite continued high risk), and insufficient supervision given two staff were managing 19 patients with competing duties during a busy morning shift.