Coroner's Finding: MIDDLETON Geraldine Ruth

45y · Female·haemorrhage due to traumatic rupture of the liver

A 45-year-old woman with a long history of bipolar disorder and personality disorder presented to the ED at 2:30 AM after cutting her wrist deeply with a carving knife. The treating casualty officer did not properly document a mental state examination, failed to detect signs of active psychosis (auditory hallucinations), and did not detain her under Mental Health Act despite high-intent self-harm, uncommunicative presentation, and extensive prior scarring. When she absconded from hospital at 4:45 AM, police were called but she was not detained. The ACIS team visited that afternoon but inadequately documented their assessment and failed to escalate after she self-harmed again hours later. That evening she left the flat; hours later she was struck by a train and died from liver rupture. The coroner found inadequate mental state assessment, failure to recognize suicide risk despite psychotic symptoms and recent serious self-harm, poor documentation, lack of detention despite clear indications, and inadequate inter-service coordination between hospital and ACIS.