Inquest into the death of Lynda Vanessa CLIFFORD

Contributing factors

• discharge on six CNS-depressant medications simultaneously including three antipsychotics
• incomplete discharge summary with inaccurate medication list
• failure to include Clopixol on discharge summary despite continued administration
• failure to communicate anticipated treatment plan for medication rationalization to community providers
• discharge summary not received by GP or private psychiatrist
• discharge summary not sent to methadone clinic
• lack of coordination between hospital, community mental health service, GP, and private psychiatrist
• failure to reduce Seroquel as Clozapine took effect despite patient stability
• excessive repeats issued for Seroquel without clinical review
• inadequate family education and communication at discharge
• continuation of Clopixol by community mental health service with incomplete documentation
• fluoxetine inhibition of methadone metabolism increasing plasma levels
• absent communication from private psychiatrist with hospital after discharge
• absence of documented discharge care plan

Coroner's recommendations

1. Review discharge summary procedures to ensure adequate medication details, treatment plan information, and dissemination to all necessary recipients including methadone clinics, with administrative confirmation of receipt
2. Review local discharge planning process to assess implementation of Discharge Planning Directive requirement for creation and provision of Care Plans to patients
3. Develop standardised document for patients/families at discharge including diagnosis, medication regime, next appointment details, and after-hours contact information
4. Amend NSW Opioid Treatment Program Clinical Guidelines to highlight fluoxetine interaction with methadone and capacity to increase plasma levels
5. Reinforce through education and training importance of accurate medication recording on discharge summaries and documentation of decisions to cease medications
6. Reinforce through education and training desirability to limit repeat authorizations for antipsychotics to clinically indicated cases
7. Reinforce through education and training importance of charting depot medication authorizations and administration at CMHT
8. Reinforce through education and training importance of communication of current and proposed treatment plans between community providers after discharge from mental health units