Inquest into the Death of Carole LIVESEY

54y · Female·unascertained

Carole Livesey, a 54-year-old woman with severe anorexia nervosa and major depression, absconded from Rockingham Hospital psychiatric unit on 3 October 2017 during an escorted walk in hospital grounds. She had been an involuntary patient admitted on 7 September 2017 following multiple suicide attempts. Though found wet and distressed (suggesting attempted drowning) by the Salvation Army, police failed to attend within the critical timeframe due to resource constraints and she disappeared. The coroner found she likely died around the time of absconding from suicide. Key clinical lessons: (1) Consulted psychiatrist, not registrar alone, should approve involuntary patient leave; (2) Progress risk assessments must be completed before leave; (3) Knowledge of patient's prior absconding history should inform risk assessment; (4) Eating disorder services require multidisciplinary coordination from admission; (5) Family should be consulted for relevant clinical information when assessing leave decisions; (6) No psychologist input despite availability; inadequate eating disorder specialty care.