Inquest into the death of Daniel Alexander Bleaney

Contributing factors

• acute psychosis with command hallucinations instructing suicide
• recent serious suicide attempt (jumped from ship)
• admitted to open (non-secure) psychiatric ward despite high suicide risk
• inadequate level of nursing supervision (15-minute observations vs. one-to-one)
• ward courtyard fence known to be scalable by athletic patients
• lack of implementation of security improvements after prior 2015 death
• staff misperception that Cowdy Ward was secure
• patient appeared compliant and well-mannered, masking serious ongoing suicidal intent
• failure to keep alive institutional memory of prior death from same ward
• lack of staff induction on known risks
• communication failures with family regarding ward security status

Coroner's recommendations

1. That Top End Health Service ensure such alterations are made to the courtyard in Cowdy Ward so as to prevent absconding over the fence
2. That induction and training of all staff include an appropriate description of the security status of Cowdy Ward and appropriate mitigation strategies to mitigate the known risks
3. That TEMHS take all appropriate steps to ensure that Cowdy Ward is a physically secure ward, including the construction of a courtyard fence that is fit for purpose while not detracting from the therapeutic environment
4. That TEMHS review the way that it assesses patients, including their risk of suicide, and educates staff on risk assessment and appropriate steps following risk assessment
5. That TEMHS review its guidelines around the use of one-to-one observation ('specials') for patients in Cowdy Ward and educate staff on availability, need and requirements
6. That TEMHS implement a policy in relation to the conduct of 15-minute observations, including information to be noted, relationship to risk assessment, and accountability for proper conduct
7. That the psychiatric consultant and/or registrars responsible for patient care each day perform a ward round before leaving for outpatients or attend the morning handover meeting
8. That TEMHS cease using the term 'take own leave' in relation to involuntary patients and replace with 'abscond' or 'AWOL'
9. That TEMHS conduct review and further training for all staff in relation to appropriate, responsive and timely steps in event of patient absconding, including rapid search protocols and notifications
10. That TEMHS implement a policy or protocol around meeting with families of deceased patients, including necessary information to be obtained before a meeting to ensure it is useful and minimises further distress
11. That the above policies, procedures and protocols are regularly reviewed, updated, kept contemporaneous and available to all staff, and are available during staff orientation
12. That TEMHS audit and monitor the progress of key findings and recommendations in a meaningful way to ensure gaps in improvements are not lost