Inquest into the death of Frederick PEISLEY
Deceased
Frederick Peisley
Demographics
58y, male
Date of death
2012-12-16
Finding date
2016-12-16
Cause of death
blunt force head injury
AI-generated summary
Frederick Peisley, an Aboriginal man with acquired brain injury and schizoaffective disorder, died from a head injury after falling from stairs at an aged care facility. Critical failures included poor communication of his Community Treatment Order (CTO) across healthcare settings, inadequate psychiatric supervision, insufficient clinical information provided to the assessing GP on the day of his death, and lack of escalation to mental health services despite multiple documented suicide-related behaviours on 9 and 13 December. The coroner found that proper information sharing regarding his CTO, more intensive clinical supervision, and complete handover of his recent behavioural history to the GP would likely have led to mental health assessment and transfer, preventing his death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- failure to communicate Community Treatment Order across healthcare settings
- inadequate psychiatric supervision of junior doctor with minimal experience
- incomplete clinical information provided to assessing GP
- failure to escalate to mental health services despite suicidal behaviours
- inadequate documentation of behavioural escalation
- lack of coordination between CTO case manager and treatment team
- insufficient monitoring despite suicide risk
Coroner's recommendations
- Expand access to electronic medical record systems (Cerner, CHIME) across NSW Health LHDs and SHNs to improve information sharing
- Include copies of Community Treatment Orders in HealtheNet Portal summary information
- Implement training for clinicians (RNs and doctors) on general medical wards about CTOs, their purpose, and the role of case managers
- Ensure trainee psychiatrists receive comprehensive training on CTOs including legal implications and when they terminate
- Develop policies and implement staff training at The Ritz for identifying and managing suicidality, depression, and psychosis among residents
- Conduct formal risk assessment of all internal and external staircases at The Ritz considering residents' age and complex needs
Full text
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