Inquest into the death of Mitchell FLOOD-SMITH
Deceased
Mitchell Flood-Smith
Demographics
23y, male
Date of death
2017-05-04
Finding date
2019-12-04
Cause of death
Multiple injuries sustained following collision with a train
AI-generated summary
A 23-year-old man with a history of schizophreniform disorder, depression, and previous suicide attempts absconded from a mental health triage facility after being involuntarily admitted. He had previously absconded in 2016, reported planning to stand on railway tracks, and exhibited clear suicide risk. Paramedic records documenting his railway track planning were not reviewed by nursing staff prior to his absconding. Security staff were temporarily absent from the reception area when he left. Police were notified 30 minutes after absconding without critical information about his railway track ideation. The deceased died by deliberate train collision approximately 1 hour 51 minutes later. Clinical lessons include: urgently reviewing paramedic records during triage assessment; maintaining continuous security presence; immediate police notification with complete risk information including specific methods mentioned; formalising risk assessment protocols for absconding history; and improving communication between mental health and police services regarding detained patients.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
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
- 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
- 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
- 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
- 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
Full text
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