AN INQUEST INTO THE DEATH OF PAP

Contributing factors

• Patient's refusal to accept medical treatment and services offered following discharge
• Non-compliance with anticoagulation therapy (Warfarin)
• Alcohol dependence and heavy daily consumption
• Living in squalor with poor self-care
• Hoarding behaviour and extreme home disarray
• Failure of health services to share information across mental health and physical health providers
• Healthcare providers' misunderstanding of privacy legislation limiting appropriate referrals
• Closure of mental health file on hospital admission, preventing cross-service communication
• Inadequate follow-up and monitoring post-discharge from John James Hospital
• Lack of coordinated, whole-of-person care approach

Coroner's recommendations

1. ACT health care providers should be reminded through ongoing professional development and/or training about the extent and application of privacy law, particularly its relationship to lessening or preventing serious threat to life, health or safety of an individual within the ACT.
2. ACT health care providers should be reminded they have the capacity to ensure referrals can be made to relevant agencies that might provide support to a person, recognising that it remains the person's right to accept or decline that support.
3. ACT health services should examine their capacity to cross-reference relevant data management systems, particularly mental health and physical health service providers, to enable health service providers to interact with respective data management systems so as to provide timely access to relevant medical information for health care professionals to effectively diagnose, treat and deliver in-hospital or post-discharge care having been able to consider holistically a patient's various medical conditions.
4. Implementation of a flagging mechanism (e.g. colour-coded) on patient medical records that could indicate areas of health care provided to the patient historically and currently (e.g. identifying patients with Psychiatric Treatment Orders or underlying mental health conditions) without necessarily disclosing the illness or treatment regimes, to alert health care professionals that broader medical considerations may need to be addressed.