Inquest into the death of Benjamin Woodhouse

Contributing factors

• Inadequate risk assessment by AFEA Care Services
• Inadequate risk assessment by Primary Care and Community Services
• Failure to communicate patient's history of water entry and suicidal ideation to carers
• Lack of written conditions of leave
• Carer lacked mental health training
• Delayed police notification
• Insufficient information provided to police for effective search
• Deficient care planning by AFEA
• No incident reporting system linking to care plan updates
• Absence of behavioural support plan
• Conditions of leave not documented in writing

Coroner's recommendations

1. The LHD amend its leave form to be provided to the patient, family and any third-party carer to record the conditions of leave which must be complied with.
2. Where it is proposed to send an involuntary patient on leave the LHD provide a written summary to both support coordinators and care providers of a patient's history, diagnosis, trigger points, risk, behaviour management techniques and what to do in an emergency, e.g., if the patient absconds.
3. PCCS review current management of and compliance with its risk policy and procedures in light of this case and conduct risk assessments on intake as well as when significant events occur.
4. PCCS require a support co-ordinator to contact police and/or ambulance as soon as it is notified that a client who is an involuntary patient absconds from a carer except where such contact with police and/or ambulance has already occurred.
5. AFEA institute a risk assessment process for each client (who is an involuntary patient) which includes a regular review of such risk assessments including when relevant circumstances change.
6. AFEA make it plain to its support workers and care co-ordinators that they are expected to contact police and/or ambulance as soon as a client who is an involuntary patient absconds from a carer.
7. PCCS and AFEA each develop a form based upon the NSW Police 'absconded patient – report to police' form, containing relevant information to provide to the police and any other relevant agency, which sets out full information about the circumstances of the absconding.
8. The Commissioner of Police consider amending the absconded patient report to police form to include a requirement to specify where the patient was last seen, by whom and the contact details of the person who last saw the patient.