A Wellington woman could have been dead for two hours before she was found in her bed in a locked hospital ward - despite being observed every 15 minutes by nurses.
Zoe Margaret Norton Purves, 23, was found dead at Kenepuru Hospital on July 27, 2011, after being admitted. She had been on a 15-minute observational watch after telling people in the days before that she wanted to end her life.
It had been reported that she was breathing an hour before she was found at 10.30am. A nurse then said she was stiff and cold when she was found.
Regional forensic pathologist John Rutherford, giving evidence at the inquest of Ms Purves yesterday, said it was generally accepted that rigor mortis set in some two hours after death. It was unlikely she had been dead less than an hour.
Ms Purves' mother, Anne Norton, had told the inquest that she was concerned about how the observations were carried out, and found it hard to understand how her daughter could have taken her own life while under watch.
Responding to a question from the family's lawyer, Matthew Palmer, about the timing, Dr Rutherford said he could accept that death could have occurred between 8.30am and 10.30am.
Clinical nurse specialist Roy de Groot admitted that the observation procedures were inconsistent when checking Ms Purves. New procedures required checks for signs of life, such as breathing.
However, he added that he might not check a sleeping patient, and there might be good reasons not to follow the procedure to check for signs of life. But if there was concern for the safety of the patient, they should be checked.
Nurses had to exercise some judgment, he said.
Patients were not automatically searched when they arrived at hospital, although he expected nurses to go through their belongings with them.
Alison Masters, clinical director for Capital & Coast District Health Board's mental health directorate, said it was apparent there should have been a higher level of observation for Ms Purves.
Coroner Ian Smith reserved his decision.
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