Cif Lee Ja 20040930

Contributing factors

• violent physical restraint by multiple staff members
• prone positioning during restraint
• application of broad force to the front of the neck
• pressure applied to back and chest by restraining staff
• handcuffing without medical authorization
• administration of multiple intravenous psychiatric medications
• no senior medical officer physically present on the ward during incident
• communication between ward staff and doctor by telephone only
• staff inadequately trained in aggressive behavior management techniques
• ambiguous and conflicting protocols regarding restraint procedures

Coroner's recommendations

1. Funding be provided for all Mental Health Unit staff including security to undertake Aggressive Behaviour Management Training
2. Dedicated security staff be attached specifically and permanently to the Mental Health Unit rather than the hospital generally
3. Aggressive Behaviour Management Training be recognized as a long-term project with funding for regular refresher courses
4. Funding be provided to fill staff positions necessarily vacant while personnel undertake training and refresher courses
5. All newly recruited and commencing staff, including medical staff and security, undertake Aggressive Behaviour Management Training before commencing employment
6. The document 'Management of adults with severe behaviour disturbance, guidelines for clinicians' be distributed to all health professionals before commencement at the Mental Health Unit
7. A policy be developed for more effective communication between ward staff and treating doctors regarding approval of restraints
8. The Aggressive Management Behaviour Training manual be reviewed to remove ambiguity regarding prone positioning during restraint
9. Queensland Health undertake a complete review of policies and procedures for managing aggression incidents across Mental Health Units
10. The term 'takedown' be removed from training literature and replaced with 'restraint' to reflect more humane patient treatment
11. A policy and procedure officer be appointed to review policies and ensure proper ongoing communication of procedures to all staff
12. An incident management officer be appointed full-time to the Mental Health Unit to monitor clients for potential incidents
13. Funding be provided for a male indigenous health worker on the ward to cater for special needs of indigenous male clients
14. Queensland Health undertake a review of appropriate professional staffing levels to ensure a doctor is present on the ward
15. Funding be provided for additional medical staff in the Mental Health Unit
16. Queensland Health undertake a review of how incidents of aggression are monitored and recorded
17. Establish committees within Mental Health Units to analyze trends in reported aggression incidents
18. Funding be provided for architectural renovation to provide clear view from the nurses' station to the entire ward