Findings Into The Death Of Mijo Galinec

Contributing factors

• failure to communicate psychiatric risk during clinical handover
• incoming nursing staff not informed of suicidal ideation or mental health status
• inadequate observation protocols for psychiatric patients on general medical wards
• absence of standardised absconder procedures and reporting forms
• lack of secure access/egress monitoring on general ward
• delayed reporting of patient absence (time discrepancies in documentation)
• incorrect information provided to police about absconding patient's clothing
• shortage of dedicated psychiatric beds limiting appropriate placement
• open ward environment without capacity to secure psychiatric patients

Coroner's recommendations

1. ACT Health should require review of handover protocol by Clinical Handover Standards Group, potentially requiring staff to review basic handover sheet highlighting risk issues before commencing clinical duties
2. ACT Health should develop a Standard Operating Procedure and report form for patients who abscond from wards to guide staff in gathering information and informing appropriate personnel in timely and accurate manner
3. ACT Health should consider securing or monitoring access to and egress from wards other than dedicated psychiatric wards which accommodate mobile patients with psychological or mental illness
4. ACT Health should amend Mental Health policies to address circumstances of patients with psychological or psychiatric conditions housed in non-psychiatric units such as MAPU, including observation protocols for suicidal patients