52 results for “ligature removal”
59y · Female·Hypoxic ischaemic brain injury secondary to compression of the neck in the circu…
…luntary inpatient at a private psychiatric clinic. She was assessed as low-risk and had no restriction on ligature access. Despite recent suicidal ideation, her psychiatrist did not escalate her risk category after she e…
60y · Male·Global cerebral ischaemia post cardiac arrest in the setting of neck compression
…r attempts was inadequate; treating teams must access complete medical records and prior suicide methods; ligature items must be removed from Low Dependency Units regardless of whether risk is deemed 'chronic' versus 'ac…
65y · Male·Hanging
…ght downgrading of observations to hourly intervals without formal psychiatric review, and (2) accessible ligature points including window winders in patient bedrooms. These were system-level failures, not individual cli…
43y · Male·asphyxia due to hanging - suicide
…or supervision contributed to his death. However, the case identified a public safety issue regarding non-ligature-proof door handles at the facility. This has subsequently been addressed through retrofitting with anti-l…
64y · Female·hypoxic ischemic encephalopathy caused by neck compression and hanging
…ord/drawstring and died by hanging. The death occurred in the context of inadequate search procedures for ligature risks, particularly inconsistency between low dependency and high dependency units. Staff believed harmfu…
24y · Male·complications of ligature compression of the neck (hanging)
…itial improvement and no overt behavioural indicators of imminent suicide risk, he hanged himself using a ligature fashioned on a shower head. The coroner found hospital care was appropriate and of reasonable standard. K…
39y · Female·Hypoxic brain injury secondary to hanging
…thinking at admission, she was assessed as low-risk and placed in the Low Dependency Unit without routine removal of potential ligatures. Critical clinical gaps: no daily formal risk assessments conducted (only ad-hoc p…
39y · Female·hanging
…l management overall appropriate and the death difficult to predict. However, the coroner identified that ligature risk assessments at TMC had failed to identify hazards, noting two further hanging deaths at TMC in 2012.…
50y · Male·Hanging
…e coroner found his death was preventable because wardrobe hinges in his room—identified as a medium-risk ligature point in 2016 and 2017 audits—were not removed despite over two years passing. The 2018 ligature audit fa…
53y · Male·ligature compression of the neck (hanging)
…aged psychiatric patients with no suicidal history may act on impulse, and that identifying all potential ligature points in open wards involves balancing safety against therapeutic benefit.
41y · Male·ligature strangulation
A 41-year-old man with intellectual disability, autism spectrum disorder, and psychosis died by ligature strangulation using his shoelaces in an acute mental health unit. He had been admitted involuntarily foll…
55y · Male·Hanging
…tient unit on 25 February 2017, just hours after admission as a compulsory patient. He used his belt as a ligature. The coroner found the death potentially preventable, criticising the failure to remove personal items th…
22y · Male·aspiration pneumonia complicating resuscitation for cardiac arrest due to neck c…
… deficiencies: wardrobes created blind spots obscuring one bed from the doorway, the wardrobe served as a ligature point, and loose electrical cords were accessible. These hazards had been identified in previous safety a…
37y · Female·Hanging
… psychosis rather than true delusional disorder. The ensuite door and handbag strap provided unrecognised ligature points. Key learning points: (1) diagnostic certainty is challenging in plausible delusions and impacts p…
47y · Female·Neck compression (ligature strangulation)
A 47-year-old woman died by ligature strangulation using pantyhose while in police custody after arrest on outstanding warrants. She had docum…
41y · Male·Ligature compression of the neck (hanging)
Shane Nathan Roberts, aged 41, died by ligature compression (hanging) in Hakea Prison on 24 June 2019. He had pre-existing depression and anxiety treated…
41y · Male·Hanging
A 41-year-old male prisoner with a history of depression died by suicide while incarcerated at Wolston Correctional Centre. He was appropriately assessed as low-risk for suicide on arrival and received psychiatric care a…
75y · Male·neck compression due to hanging
…ency units. Key deficiencies included lack of documented assessment of suicide risk and failure to remove ligature risks such as pyjama cords. The coroner emphasised that clinicians managing detained patients must docume…
41y · Male·ligature compression of the neck (hanging)
Owen Weazel, a 41-year-old Wakka Wakka man with chronic mental health issues, substance use disorder and previous suicide attempts, was found hanging in his cell at Albany Regional Prison on 10 August 2023. He had been r…
29y · Male·hanging
…iatrist's assessment of low suicide risk was reasonable. However, deficiencies in communication about his removal to Malaysia were identified. The coroner found it was not possible to foresee this particular risk and re…
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.