Inquest into the death of Ahlia RAFTERY

Contributing factors

• inappropriate ward transfer from LMMHU to NMHU despite psychiatrist not being consulted or informed
• incomplete communication of previous self-harm attempts during handovers
• downgrading of suicide risk classification from high to medium despite high-risk indicators
• ineffective observations during nursing handover period
• inaccurate recording of observations using 'block recording' practice
• inadequate risk assessment processes
• lack of holistic consideration of patient needs in determining observation levels
• staffing constraints and PICU overcrowding
• ward lighting and visibility issues affecting ability to detect hanging
• insufficient time for nurse manager to conduct comprehensive patient assessment prior to night shift

Coroner's recommendations

1. Amend procedures and policies regarding transfer of patients between mental health services to include mandatory requirement that patients are not transferred without agreement from consulting psychiatrist or member of medical treating team
2. Provide specific targeted training to all mental health clinical staff regarding changes in patient care policies introduced since March 2015
3. Provide ongoing periodic training to mental health clinical staff regarding holistic consideration of patient needs in determining observation levels
4. Provide increased and regular education and training to nursing staff regarding completion of patient observation charts to ensure accurate recording at times performed and avoid 'block recording' practice
5. Amend Mental Health: Levels of Observation – PICU policy to ensure clear instructions regarding performing observations day and night and how to ensure patient safety
6. Develop policies and procedures to clearly identify roles and duties of incoming and outgoing nursing staff during handover times, particularly regarding responsibility for observations during handovers
7. Consider conducting independent trial of back-to-base pulse oximetry units for continuous monitoring in mental health intensive care units if Black Dog Institute grant application is unsuccessful
8. Forward findings to NSW Minister for Health for consideration with Black Dog Institute innovation grant application for pulse oximetry trial
9. Give consideration to increasing nurse-to-patient ratios within Psychiatric Intensive Care Unit of Mater Mental Health Centre to ensure patient safety is not compromised