Inquest into the death of Naomi Watson Ley

Contributing factors

• inadequate diagnostic assessment - failure to access prior discharge summary documenting severe treatment-resistant depression and ECT
• insufficient washout period between moclobemide and citalopram (36 hours instead of 10-14 days recommended)
• discharge with citalopram 30mg instead of recommended 10mg starting dose
• failure to contact prescribing GP
• inadequate discharge planning and communication to mother
• lack of written discharge plan
• discharge summary not completed until 25 June, not sent to GP
• failure to fully investigate longitudinal psychiatric history despite documented difficulty obtaining full history
• possible masking of depression by benzodiazepines and antipsychotics during hospital stay
• medication changes prescribed in community without psychiatric input

Coroner's recommendations

1. A policy be implemented that with respect to patients discharged from Mental Health Units (including Emergency Mental Health Units), in circumstances in which a discharge summary will not be available to be sent so that it is received on the day of discharge by a patient's GP and (i) where follow-up by a GP is recorded as part of that patient's discharge plan or (ii) where medications commenced by that GP are to be discontinued, a member of the medical or nursing staff of the hospital should attempt to contact that GP to provide relevant information about the patient's presentation and discharge plan
2. Consider implementing a standardised policy for the practice of recording and auditing notes, including recording the source of history in clinical notes
3. Ensure discharge summaries are completed in an appropriate timeframe
4. Provide patients and carers with a comprehensible written discharge plan
5. Obtain discharge summaries from previous treating facilities when appropriate