Royal Hobart Hospital coroner finds missed opportunity in patient suicide

A coroner has identified a “missed opportunity” regarding the care of an 82-year-old woman who died by suicide at the Royal Hobart Hospital. The woman, who had been living independently, became distressed after a medical consultant discussed the possibility of her moving into aged care.

While hospital records noted her low mood and frustration, a doctor chose not to wake her to discuss her distress when she was asleep during an evening review. The coroner found that the hospital lacked adequate processes to ensure patients experiencing acute mental health deterioration were rapidly referred to mental health services. In response, the Tasmanian Health Service has provided additional training to staff, and the coroner has recommended a systemic review of how hospitals recognize and respond to acute mental wellbeing deterioration.