Inquest into the deaths of Shaneen BATTS, Ilona TAKACS, Dorothy HUDSON, Ian BIRKS, Donald MacKELLAR and Mohammed RAMZAN

Contributing factors

• Polypharmacy with antipsychotic medications without adequate monitoring
• Failure to manage documented physical health risk factors and comorbidities
• Antipsychotic dosing not adjusted for significantly low body weight
• Inadequate medication compliance monitoring and record-keeping
• Insufficient coordination between psychiatrist and general practitioners
• Minimal professional supervision—one unqualified staff member for up to 35 weekend residents
• Staff with no first-aid or emergency response training
• Poor facility standards: unhygienic conditions, inadequate nutrition, unsafe infrastructure
• Inadequate medical documentation preventing continuity of care
• Infrequent psychiatric reviews and no formal communication between doctors
• Regulatory oversight failures by Department of Ageing, Disability and Home Care

Coroner's recommendations

1. Mandatory registration of all boarding house operators accommodating two or more persons
2. Boarding house reform legislation addressing accommodation standards, service standards, and occupancy protection for tenants
3. Establish a regulatory body separate from DADHC with powers to monitor, prosecute, and arbitrate disputes; mandate reporting of breaches by employees
4. Government financial assistance and incentives to encourage boarding house operator compliance with legislative requirements
5. NSW Health to establish protocols for annual mandatory health reviews for residents in boarding houses with mental illness or conditions
6. Royal Australian & New Zealand College of Psychiatrists to review all six deaths and establish clearer protocols for monitoring multiple antipsychotic medications in longer-term mental health patients