Inquest into the death of Roger Frederick Schnelle

Contributing factors

• psychotic depression (or anxiety disorder with depressive features)
• inadequate risk assessment and escalation
• failure to increase observation levels despite clinical deterioration
• poor communication between nursing and medical staff
• inadequate multidisciplinary risk management planning
• failure to escalate concerning information from family member
• lack of electronic medical records
• outmoded risk assessment tools (tick-box system)
• unrecorded informal observation increases by nursing staff

Coroner's recommendations

1. That consideration be given to continuing to advocate with NSW Health and the Department of Health, Victoria, for the implementation of an electronic medical record across Albury Wodonga Health mental health services. Such a record should ideally be compatible with systems in both NSW and Victoria, and should include standardised documents for the assessment, formulation and management of risk and patient observations.
2. That consideration be given to a review being undertaken of the Albury Wodonga Health mental health service policy relevant to risk assessment, patient observation and documentation to ensure compatibility with both NSW and Victorian policies. Where those policies are not compatible, draw this to the attention of NSW Health and the Department of Health, Victoria, in accordance with the process described in the AWH Memorandum of Understanding.
3. That consideration be given to implementing Risk Assessment Tools that focus on assessment, formulation, and importantly management of risk and consider risk indicator factors that are associated with an increased suicide or suicidal behaviour, as set out in the expert evidence of Dr E..
4. That consideration be given to ensuring that the induction processes for locum and visiting staff members clearly identify relevant policy and practices in relation to the assessment, formulation and management of risk documentation and patient observations.