Inquest into the death of CC

Case Number: 2022/147991

Findings Date: 15 December 2023

Magistrate: Erin Kennedy

CORONIAL LAW | High Dependency Unit; psychiatric care; Nepean Hospital; self-harm in psychiatric ward; mentally ill person; reduction of hanging points; highlighting of events in medical records

Responses

Recommendations

Nepean Blue Mountains Local Health District

That the Nepean Blue Mountains Local Health District consider whether it would be appropriate to implement a process in the mental health ward, whereby nursing staff can highlight events they consider significant in the electronic medical record, with a view to drawing attention to such events for future nursing shifts and/or the treating team.