Inquest into the death of Channa

Contributing factors

• discharge from mental health care without adequate planning
• homelessness and lack of confirmed accommodation
• failure to meet allocated case manager prior to discharge
• lack of drug and alcohol intervention despite documented substance use disorder
• labelling as 'malingerer' without formal assessment, creating clinical barrier
• poor communication between services and with family
• lack of continuity of care and established therapeutic relationship
• inadequate reassessment on re-presentation to ED on days 1-2 after discharge
• no recognition of complex high-risk patient requiring dedicated management
• recent psychotic symptoms and expressed suicidal ideation
• homelessness as critical stressor exacerbating mental illness

Coroner's recommendations

1. NNSWLHD develop local guidelines and training regarding the use of the term 'malingering', specifying the need for recognised assessment tools and making clear that use of the term can be a barrier to treatment, with ongoing audits after implementation
2. NNSWLHD make representations to the Ministry of Health regarding need for review and update of statewide policy on malingering through wide-ranging consultation with appropriate experts
3. NNSWLHD engage in advocating for dedicated housing in the local area for mental health patients as a matter of urgency
4. NNSWLHD create policy to ensure all mental health inpatients diagnosed with substance use disorder have access to drug and alcohol counselling during and after release
5. NNSWLHD establish adequate quality control mechanisms to check information provided to Mental Health Review Tribunal for Community Treatment Orders, including carer and address information and confirmation of contact between case manager and patient prior to discharge
6. NNSWLHD continue regular audits to ensure patients with multiple ED presentations for mental health issues are appropriately managed in compliance with complex case policies and procedures