Inquest into the death of Mitchell FLOOD-SMITH

Contributing factors

• Absconding from Triage and Assessment Centre before psychiatric assessment
• Paramedic electronic medical record not reviewed by nursing staff prior to assessment
• Specific railway track method planning not communicated to assessment staff or police
• Security officer absent from reception area when patient absconded
• Delayed notification to police (30 minutes after absconding)
• Information about railway track ideation not provided to police in missing person notification
• Lack of alert in electronic medical record documenting previous absconding history
• Patient placed in non-secure reception area despite involuntary detention status
• No immediate clinical follow-up of patient's failure to attend scheduled appointment

Coroner's recommendations

1. Review arrangements of Nepean Hospital's Triage Assessment Centre regarding nurses and staff review of electronic records submitted by paramedics for patients admitted under the Mental Health Act 2007
2. Review practice and procedures regarding timing of notifications made to NSW Police Force about involuntarily admitted patients who have absconded and information to be provided in such notifications
3. Review arrangements for securing persons involuntarily detained under the Mental Health Act pending psychiatric assessment, with focus on how to prevent patients absconding before assessment
4. Review clinical practice guidelines for assessment and management and documentation of patient's risk of absconding, including criteria for determining such risk, predictive value of past instances of absconding, and education and training of clinical staff