Finding into death of Judith Mary Pollard

73y · Female·Complications of lipoid pneumonia following the ingestion of shampoo, conditioner, toothpaste and inhalation of hairspray

Judith Pollard, a 73-year-old woman with an extensive mental health history, was voluntarily admitted to Shepparton Private Hospital on 1 June 2023 following acute depression and paranoia. Despite her family informing staff of her previous suicide attempt by hanging in hospital and requesting close monitoring, she was placed on 30-minute observation intervals. On 2 June 2023, nursing staff found her vomiting after she had ingested shampoo, conditioner, toothpaste, and inhaled hairspray in a suicide attempt. She developed lipoid pneumonia and died 18 days later. The coroner found that nursing observations occurred at predictable times (on the hour and half-past), allowing Judith to recognise the pattern and ingest products undetected. While random observations might not have prevented her death, the hospital's failure to implement unpredictable observation intervals as per policy was identified. The coroner commended subsequent safety improvements restricting patient access to personal care products.