The Royal Hobart Hospital did not have adequate systems in place to recognise and respond to patients whose mental wellbeing was rapidly deteriorating, a coroner has found.
Coroner Olivia McTaggart handed down her findings into the death of an 82-year-old woman who took her own life while a patient at the hospital in September 2024.
The woman had lived independently at her Moonah home before she was admitted with a number of serious health conditions.
A Department of Health root cause analysis found staff had missed an opportunity to respond to the woman’s suicidal ideation in line with best practice.
That would have involved conducting a full suicide risk assessment to determine the seriousness of her intent, McTaggart said.
She said the review found staff followed all existing processes, but there was “a lack of essential systems and processes regarding a response to an acute deterioration in a patient’s mental well-being”.
As a result, the hospital did not have processes ensuring compliance with national standards, including those that “ensure rapid referral to mental health services to meet the needs of patients whose mental state has acutely deteriorated”, she said.
McTaggart said the woman had become distressed the day before her death after a medical consultant raised the possibility she move into residential aged care.
That evening, she told her daughter she did not “want to go on anymore” and “wanted to die”.
Hospital records noted her mood was down and that she was frustrated at her lethargy and her inability to feed herself.
Her daughter, concerned she was suicidal, alerted nursing staff, who requested a doctor review her.
But when the doctor arrived that evening the woman was asleep and was not woken, McTaggart said.
The coroner said she did not consider hospital staff “could have reasonably foreseen that [the woman] would choose to end her life at that time, nor that she had the ability to carry out her intentions as she did”.
The root cause analysis found the hospital’s Comprehensive Care Plan, a tool meant to help identify patients at risk of self-harm, was completed on only five of the woman’s 11 days in hospital and was not designed to assess mood or emotional wellbeing.
McTaggart said the hospital had since improved its care planning and, from January 2026, added mental state deterioration to its Adult Deterioration Detection System.
Staff had also received training.
She recommended the Tasmanian Health Service review how well the framework was working over time and make any changes needed.
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