Djordevic final

Contributing factors

• Failure of communication between general practitioners and hospital regarding schizophrenia diagnosis
• Failure of community mental health service to communicate with hospital obstetric team
• Poor understanding of clozapine by obstetric and general practice staff
• Failure to arrange mental health assessment during pregnancy and labour
• Non-compliance with medication management policy allowing patient to self-administer clozapine
• Discontinuation of clozapine leading to relapse of psychosis
• Inadequate psychiatric input into medication prescribing on mental health unit
• Failure to maintain observation after placement in seclusion
• Multiple breaches of essential restraint safety requirements including insufficient staff, no supervision, failure to monitor breathing and colour, excessive duration

Coroner's recommendations

1. Conduct statewide review of hospital directive 'Seclusion Practices in Psychiatric Facilities' with consideration of continuous observation requirement when patient placed in seclusion
2. Clarify Local Health Network policy Patient Care Levels for Acute Mental Inpatient Units with discrete statement requiring continuous observation when patient placed in seclusion
3. Conduct statewide review of restraint policies and practices across all hospital departments with consideration of direction to avoid prone restraint if at all possible and consequent staff training and retraining
4. Forward findings regarding manner and dangers of prone restraint to Australasian College for Emergency Medicine and Royal Australian and New Zealand College of Psychiatrists for information and policy consideration
5. Forward findings regarding potential dangers of ingestion of toothpaste to Department of Health for information and consideration
6. Forward findings regarding communication of mental health diagnosis in pregnancy to Royal College of General Practitioners and Royal Australian College of Obstetricians and Gynaecologists for professional development programs