Coroner's Finding: SANDERS Sandra June

42y · Female·salt water drowning

Sandra Sanders, aged 42, a detaineε psychiatric patient, died by saltwater drowning after absconding from Woodleigh House psychiatric unit on 3 September 1997. She had presented with major depression with psychotic features following a recent suicide attempt, and was appropriately detained under the Mental Health Act. The coroner identified critical failures in implementation of care: (1) Dr K.'s request for 'close supervision' was not translated into action by nursing staff, (2) staff failed to detect two unnoticed absences (2 and 3 September), (3) grossly inadequate documentation from 2 September until after she disappeared, and (4) slow response (3+ hours before police notified at 3.50pm). Had the absences been detected, Dr K. stated she would have implemented one-to-one nursing or transfer to a closed ward. The coroner found significant lapses in nursing care quality and emphasized that detained patients require clearly specified observation protocols with proper documentation.