Inquest into the death of Stephen Douglas

Contributing factors

• No psychiatrist review for 6 months after Community Treatment Order expiry despite high risk of deterioration
• Absence of formal mental health shared care plan between GP and community mental health service
• Failure to implement formal Safety Huddle risk assessment process before home visits
• Dynamic risk not reassessed despite warning signs of mental deterioration in late November 2019
• Lack of coordination between GP (Dr H.) and mental health service regarding medication non-compliance and mental state changes
• Excessive caseloads for care coordinators limiting capacity for proper risk assessment and oversight
• No requirement for two-staff home visits when client showed signs of deterioration
• Incomplete administration of depot injection on 26 November with inadequate follow-up
• Single clinician home visit decision made without formal team discussion or approval from Team Leader

Coroner's recommendations

1. SLHD review Mental Health Shared Care documentation to better define roles and responsibilities of GP and mental health service, including frequency of psychiatric review, clinical review meetings, and arrangements for staff absence
2. SLHD formally implement requirement that all Community Mental Health Service clients be scheduled for psychiatrist review within 3 months of Community Treatment Order expiry and again within further 3 months
3. SLHD create flag or alert in electronic records identifying due date for periodic psychiatric reviews, visible in individual records and staff caseload reports
4. SLHD amend Core Team Model of Care guideline to set maximum caseload of 30 clients with trigger for review at 25 clients
5. SLHD maintain rostering of at least 2 accredited persons (able to schedule under Mental Health Act) within all CMHS Core Teams for all hours of operation
6. SLHD review Acute Care Service and Core Team policies to clearly define circumstances and process for transfer of Core Team clients to Acute Care Service and simplify transfer procedure
7. SLHD review Working in the Community policy to clearly communicate requirements that community/home visits not be conducted by single staff member for first visits, when mental health deteriorating, or when violence risk present or unknown; require approval of unplanned visits after morning huddle by Team Leader or senior clinician; require re-discussion if new risk information emerges before visit
8. SLHD review Community and Home Visit Huddle procedure to require discussion of dynamic safety risk assessment, recording of decision regarding conduct of visit, and re-statement of policy on when visits cannot be undertaken
9. SLHD formally implement requirement that all Community and Home Visit Huddles be attended by relevant Team Leader and psychiatrist when they form part of Core Team that day
10. SLHD formally implement requirement that new Community Mental Health Service staff cannot undertake home/community visits alone in first 3 months of employment
11. SLHD review workplace health and safety policies to consider expanding scope of daily Community and Home Visit Huddle to include general team safety issues, not only client visit safety
12. SLHD review Core Team Model of Care to include direction on handover planning for periods of staff leave
13. NSW Health consider implementation of these recommendations in Community Mental Health Services state-wide