A STATE Coroner has been scathing of Ipswich Hospital's treatment and handling of a woman who went to the emergency department, walked out naked some hours later, went to a building site, climbed a crane and jumped.
Deputy State Coroner John Lock described the events that led to the death of Melina Maree Cuttler, 29 as a perfect storm where there were many missed opportunities to treat her.
He said the phrase was one he regrettably had to use.
A three-day inquest into Ms Cuttler's death, held last month, was told family members took her to the hospital on February 12, 2013, over concerns they had regarding her deteriorating mental health.
Ms Cuttler was dead less than five hours after arriving at the hospital.
A subsequent autopsy revealed Ms Cuttler died from serious injuries associated with falling from a height of about 26m, but she had no traces of drugs or alcohol in her system.
The inquest heard Ms Cuttler was clearly in a psychotic state, but she had no history of depression, past threats of suicide or any history of self-harm.
Ipswich Hospital immediately launched its own investigation and the final report noted there were a number of system and process issues identified that may have contributed to Ms Cuttler's death.
The report made six recommendations to improve patient care at the hospital, but the coroner found that almost none of them had been implemented despite the October, 2013 deadline the hospital had given itself to do so.
Mr Lock, in handing down his findings on Friday, concluded Ms Cuttler lacked the capacity to form an intention to take her own life and ruled her death was due to misadventure.
However, Mr Lock was scathing in his assessment of the hospital saying a number of significant failings contributed to her death including a lack of leadership in decision making and the failure to escalate the situation in the face of family concerns.
He was also highly critical of the fact no medical officer examined or assessed Ms Cuttler in the 4.5 hours she was at the hospital before her death.
"I am generally satisfied the Ipswich Hospital has taken very seriously, structural and process failures, which contributed to the combination of events which all met and produced the environment for these events to occur," he said.
"I have some concerns with respect to the effectiveness and progress in implementation of the recommendations.
"Fortunately, the inquest has highlighted those matters to senior hospital staff and I have received some assurance that the hospital will take this on board."
Mr Lock further ordered the hospital report back to him within a year outlining what strategies they had implemented to ensure something like this does not happen again.
If you or someone you know needs support or information about suicide prevention please contact Lifeline on 13 11 14 or contact the Suicide Call Back Service on 1300 659 467.