Coroner's Finding: Le Roy, Carole Ann

40y · Female·hypoxic encephalopathy due to asphyxia from hanging

A 40-year-old woman with extensive mental health history including OCD, complex trauma, severe depression, and recurrent suicidal ideation was admitted to an open psychiatric unit after expressing suicidal intent. Despite being assessed as high-risk with a management plan requiring hourly observations, she was placed in an open unit rather than high-dependency or closed unit. Critical failures included: non-implementation of the hourly observation plan, placement in a room with ligature-accessible fixtures, an internally lockable door delaying staff access, and her possession of a duffle bag strap. She died by hanging within 48 hours. The coroner found admission to the open unit was inappropriate given her presentation change from previous admissions, and that post-admission care fell significantly below expected standards. The hospital's own root cause analysis acknowledged chaotic governance, poor nursing processes, lack of team structure, and inadequate systematic risk management.