Community Mental Health Patient

Contributing factors

• revocation of indefinite involuntary treatment order by less experienced registrar without consultation with consultant who made the order
• lack of written protocol requiring senior psychiatrist consultation before revoking treatment orders
• insufficient experience of front-line access team clinicians in high-risk suicide cases
• failure to readmit patient despite documented suicidal ideation and planning on 6 June
• potential deception by patient to avoid hospitalisation, not adequately assessed
• patient's resistance to hospital admission and therapeutic relationship difficulties
• rotation of case managers affecting continuity of care
• insufficient family involvement in care planning despite close family members' observations of deterioration
• comorbid substance abuse (alcohol and inhalant use) not adequately managed in community setting
• inability to enforce medication compliance once patient was voluntary
• variable clinical assessment between sister's observations and treating clinicians' assessments

Coroner's recommendations

1. The Mental Health Act should be reviewed to require consultation between treating psychiatrists or other health professionals if revocation of an indefinite involuntary treatment order is being considered by a second authorised practitioner who was not the initial practitioner who made the order. A protocol should be developed, especially where the reviewing practitioner is less experienced than the practitioner making the original order.
2. Review of the Access team structure to ensure sufficiently experienced clinicians are involved to assist patients, and continuity of team members to ensure optimal patient care from suitably experienced practitioners, especially in high-risk potential suicide patients.
3. Home visits should be considered the appropriate communication wherever there is a strong indicator that a person's mental health is declining and that the risk of suicide has increased.