Inquest into the Death of Hudson

20y · Male·Ligature compression of the neck (hanging)

Allan Kevin Hudson, a 20-year-old male with a history of depression, suicidality, substance abuse and previous sexual trauma, died by hanging on 13 August 2006 at Sir Charles Gairdner Hospital's psychiatric ward D20. He had disclosed sexual assault at age 14 and expected psychotherapy that was never provided. Although placed on 30-minute observations after deterioration on 12–13 August, nursing observations were inadequate and not conducted according to hospital guidelines. Nurse Bone failed to ensure the deceased was properly sighted and documented observations at 8pm when the patient was likely already dead outside the ward. The ward was unsecured with multiple unmonitored exits. Critical safety failures included: inadequate observation practices, unreliable medication charting, failure to escalate to involuntary status or transfer despite clear suicide risk, and lack of a secure environment. The coroner found deficiencies in observation chart design, medication dispensing processes, ward design, and nursing guideline awareness.