Inquest into the death of Sam Cain (a pseudonym)

Contributing factors

• treatment-resistant schizophrenia with exacerbation of psychotic symptoms
• acute major depressive episode with suicidal ideation and intent
• reported unobserved self-harm attempt with pyjama pants on morning of admission
• financial stressors and psychosocial stressors including grandfather's recent death
• substance abuse (cannabis, cocaine) exacerbating psychotic and mood symptoms
• no medical handover between PECC and HDU despite high-risk status
• failure of treating psychiatrist/registrar to review patient within 12 hours of involuntary detention as required by Mental Health Act
• failure to escalate observation level to Level 1 (continuous observation) despite nursing concerns about repeated door-closing behaviour
• provision of standard hospital pyjamas despite documented self-harm attempt using pyjama pants
• lack of documentation of nursing staff instructions to keep door open

Coroner's recommendations

1. Implementation of a duty psychiatrist position in the High Dependency Unit to receive handover for patients transferred from PECC
2. Outside business hours, ensure same registrar and consultant cover both PECC and HDU to streamline handover
3. Enhanced education and training for all mental health inpatient staff on suicide prevention and the importance of documenting patient observation and behaviour
4. Monthly auditing of staff meal break scheduling to ensure minimum three staff remain on duty in HDU
5. Staff re-education on preservation of emergency scenes and mandated requirements for notifying police
6. Further assessment and implementation of appropriate anti-ligature clothing in high-needs and specialist wards, with emphasis on trauma-informed and voluntary approaches
7. Enhanced collaborative processes with patient families and carers in suicide prevention planning