Inquest Into The Circumstances Surrounding The Death Of Brian Joseph Duff

Contributing factors

• Non-compliance with prescribed Clozapine medication
• Failure of Mental Health Crisis Team to conduct home visit despite requests from family and psychiatrist on evening of 14 February
• Failure to arrange police welfare check
• Lack of communication between Dr E. and case manager Mr Wilson regarding zero Clozapine blood level result
• Failure of case manager to report condition of flat (disorganisation, lack of food) to psychiatrist on 20 January
• Inadequate medication monitoring—Clozapine dispensed in 4-week batches without strict supervision
• Systemic lack of clear protocols for mental health workers managing non-compliant Community Treatment Order patients
• Absence of single point of access/triage system
• Fragmented communication between components of mental health service
• Lack of discipline-specific clinical supervision for case manager

Coroner's recommendations

1. Establish a single point of referral and entry into the ACT Mental Health Service as a matter of urgency
2. Implement a screening process to prioritise referrals based on documented guidelines with triage worker separate from assessing practitioner
3. Ensure triage worker is experienced clinician in assessing serious mental illness
4. Develop standardised assessment tool and process for all persons referred to ACT Mental Health Service
5. Clients known to be unreliable with oral medications should have strict supervision of medication intake if prescribed potent drugs like Clozapine
6. Treating doctors and case managers must collaborate and actively share information and concerns relevant to client management
7. Appraise clinicians with client management responsibilities of risk identification and risk management strategies
8. Monitor clients suspected of using non-prescription drugs through urine drug screening and educate regarding effects on mental health
9. Provide discipline-specific clinical supervision to all clinicians within the Mental Health Service
10. Develop training program in best-practice case management models for all staff with case management responsibilities
11. Review communication links between all components of Mental Health Service as matter of urgency
12. Develop individual service plan for every case-managed client with clearly identified goals and review dates
13. Ensure each client taken on by Crisis Team has documented assessment, action plan and review of outcome
14. Crisis Team staff must work in collaboration with case managers for continuity of case management plans
15. All Crisis Team contacts with registered clients must be documented in client's clinical file and move towards single accessible mental health clinical file
16. Revise Policies and Procedures Manual to address significant lack of guidelines for Crisis Team practitioners
17. Identify one staff member clearly as in charge on each Crisis Team shift—the most experienced and appropriately trained person
18. All Crisis Team staff should participate in up-to-date best practice training in crisis intervention, assessment, treatment techniques, and case management
19. Crisis Team should have direct access to identified senior registrar or psychiatrist for clinical services and staff development
20. Reprimand and professionally counsel Ms Kerri Neve and Mr Herbert Krueger for failure to fulfil their duty of care to Mr Brian Duff
21. Crisis Team assessments should be community-based in client's own environment or at Centre rather than transporting to hospital
22. Crisis Team should expand role to provide assertive follow-up and treatment in community as alternative to hospital admission