Inquest into the death of James BARTON

Contributing factors

• discharge of patient with inadequate risk assessment despite recent suicide attempts
• return of non-prescribed Xanax tablets at discharge to patient with deliberate self-poisoning admission
• lack of consultation with discharging medical practitioner regarding medication return
• patient's concealment of suicidal intentions during assessment
• resistance to mental health and drug and alcohol services engagement
• poly-substance abuse
• unstable relationship and recent relationship breakdown
• history of previous suicide attempt in 2012
• hospital labelling error on non-prescribed medication

Coroner's recommendations

1. Amend the policy 'Accountable Drugs – Handling and Recording PD2013 – 043:PCP 13' to include a requirement that where a patient is admitted with deliberate self-poisoning, the discharging medical practitioner should be consulted before the patient's own accountable drugs brought into the hospital are returned from ward storage.
2. Include in the policy a reminder that a patient's identifiable sticker/label should not be applied to the patient's own accountable drugs brought in to the hospital.
3. Bring the proposed recommendations to the attention of all staff at the relevant emergency departments involved in patient admission in the Hunter New England Local Health District.