Inquest into the death of AX

Contributing factors

• Acute psychotic illness with persecutory delusions
• Unexpected departure from ED around 4pm
• Failure to schedule patient under Mental Health Act despite clear indicators
• Senior mental health clinician failed to review clinical notes
• Failure to involve psychiatry registrar or consultant after patient left ED
• No referral made to Acute Care Services on 4 August despite clear indication for psychiatric admission
• No notification to police of vulnerable patient's departure from ED
• Poor communication between medical and mental health teams after patient departure
• Absence of 'unmanaged departure' protocol implementation
• Delay in activating acute care team referral until next morning

Coroner's recommendations

1. That as a matter of priority, a review be undertaken by SESLHD executive staff in relation to establishing a clear process and procedure for mental health consumers/patients who attend ED at Prince of Wales Hospital but leave prior to completion of treatment (unmanaged departures), including: clarification of applicable policy for unmanaged departures with operative flowcharts and the Mental Health Clinical Nurse Consultant ED Practice Guide, with consideration of appropriate staff training; and consideration of implementing appropriate clinical audits of Mental Health CNC Referral Board data and notifications on IMS+ regarding unmanaged departure incidents
2. That as a matter of priority, steps be taken to ensure mental health clinical staff in ED of Prince of Wales Hospital have clear understanding of circumstances in which consumers/patients can be scheduled under Mental Health Act 2007, including constraints on scheduling patients who have not been personally examined