Inquest into the death of Melissa STANDEN

13y · Female·Hanging

Melissa Standen, a 13-year-old with profound physical and cognitive disabilities (mosaicism), died from hanging at Westmead Children's Hospital after falling from a hospital bed at Allowah respite facility. She became entangled by her t-shirt on the bed frame corner after moving herself toward the head of the bed. Critical failures included: no formal risk assessment process for bed suitability; inappropriate bed selection (adult-sized with 23-25cm gaps unsuitable for a small child); inadequate bed adaptation (bumpers designed for seizure protection, not fall prevention); loss of critical clinical information about the child's bed configuration needs in hospital records due to system failures; and inadequate staff training, particularly for night shifts. The facility failed to involve occupational therapists in bed assessment. Prior incidents suggesting movement risk were not properly acted upon. The coroner found the death preventable, emphasizing that vulnerable children with complex needs require rigorous risk assessment protocols, appropriate equipment selection, staff training, and system integrity to maintain safety.