Barlow, Charles Edward; Lusk, Patrick Douglas; Baggott, Emily Jane

Contributing factors

• inadequate mental state examination and risk assessment
• failure to obtain collateral information from family/carers
• failure to involve family/carers in treatment planning
• lack of mental health training for general hospital medical staff
• failure to escalate to senior psychiatric services
• inadequate discharge planning
• lack of communication between services
• resource constraints and bed pressures
• lack of community support services
• cultural misunderstandings in Aboriginal mental health care
• poor handover and documentation practices
• failure to implement available mental health policies and guidelines
• lack of formal protocols between primary care and mental health services

Coroner's recommendations

1. That Queensland Health actively implement the National safety priorities in mental health strategies for reducing suicide and deliberate self-harm as a matter of priority
2. That Queensland Health actively implement the National Practice Standards for the Mental Health Workforce and Mental Health Services as a matter of priority
3. That Queensland Health actively implement the reforms of the National and Queensland Action Plans on Mental Health 2006-2011 as a matter of priority
4. That Queensland Health implement recommendations from the Public Advocate's Annual Reports 2003-04 and 2004-05
5. That Queensland Health actively implement the Guidelines for the Management of patients with suicidal behaviour or risk as a matter of priority
6. That Queensland Health accelerate implementation of Key Recommendations 1, 2, 4, 5 and 8 of the Achieving Balance Report
7. That the Director of Mental Health be given mandate and resources to provide leadership and guidance to District mental health services in implementing national safety priorities, national practice standards, and recommendations
8. That the Director of Mental Health develop and implement state-wide policy frameworks in relation to assessments, access to information, carers and network support, liaison with general practitioners, and discharge planning
9. That the Director of Mental Health monitor, review and report on Districts' implementation of reforms or create an independent mechanism for review
10. That District mental health services develop local policies to implement strategies and national practice standards taking into account local circumstances
11. That operational procedures and clinical guidelines be developed to enable staff to implement policies
12. That a strategy for active and ongoing implementation of policies be created including a training regime for all staff
13. That Executive Directors of District mental health services be accountable to Area Directors for implementation
14. That Area Directors actively monitor Districts' implementation
15. That Area General Managers be accountable for implementation and assessment of staff competency in mental health procedures
16. That the State-wide Clinical Risk Assessment and Management Training Project package be made available to all mental health professionals throughout Queensland
17. That where there is no mental health unit at a health service, patients should be assessed by mental health team/worker before discharge or a formal protocol be established
18. That wherever possible, two mental health workers complete a mental health risk assessment with Consultant Psychiatrist review if there is disagreement
19. That Queensland Health amend Guidelines to require Consultant Psychiatrist review when there is dispute between clinicians about risk
20. That Queensland Health develop and implement guideline for assessment of depression in children and young people
21. That Queensland Health develop and implement guidelines in relation to use of SSRIs for young people
22. That the Queensland Government Suicide Prevention Strategy be revised to include reference to frameworks/guidelines for suicide risk assessment
23. That Queensland Health accelerate implementation of a state-wide electronic network of patient information allowing rapid access throughout the State
24. That Queensland Health review Health Services Act provisions relating to disclosure of confidential information and implement changes to balance confidentiality with duty of care
25. That Queensland Health develop, implement and provide training in state-wide guidelines defining confidentiality issues in mental health
26. That the requirement in Health Services Act for chief executive authority in writing for disclosure of confidential information to avert serious risk should be removed
27. That consideration be given to establishing regular formal minuted meetings between public and private sector medical staff to discuss problems and generate workable action plans
28. That Queensland Government increase funding for community-based services for mental health problems in Yarrabah, Cooktown and Cairns
29. That Queensland Health identify, develop and fund community-based and culturally-appropriate alternatives to acute inpatient admission in Cairns District
30. That Queensland Health invest in programs of intensive post-discharge support for patients presenting with suicide ideation
31. That Queensland Health implement the Protocols for the Delivery of Mental Health Services in Far North Queensland Indigenous Communities
32. That Queensland Health conduct ongoing research into Indigenous peoples' understanding of mental illness and suicide
33. That Queensland Health provide funding for extension of Dual Diagnosis Mental Health/Substance Abuse Program to Yarrabah
34. That Queensland Health provide funding for detoxification program in Yarrabah
35. That Queensland Health restore in-patient capacity to Yarrabah hospital or fund culturally specific mental health programs
36. That resources be made available for establishment of an Indigenous Specific Community Mental Health Rehabilitation and Recovery Service
37. That Queensland Health develop job description for Life Promotion Officers and include them in training
38. That Queensland Health establish formal protocol between Cooktown mental health service and Cairns District mental health service
39. That Cooktown Hospital executive identify and reduce barriers to onsite training and support staff attendance at training
40. That the Memorandum of Understanding between Cooktown and Remote Area Mental Health Team be completed and signed
41. That position descriptions for rural/remote practitioners indicate competency in mental health is essential at Australian Medical Council standard and extension training is desirable
42. That Cooktown Hospital ensure mental health inpatients have identified primary nurse fully appraised of responsibilities
43. That Cooktown Hospital review complaints procedure to ensure complaints are actioned in timely manner
44. That RANIP (Remote Area Nursing Incentive Package) be available to nursing staff in Cooktown or alternative funding arrangements for nursing positions
45. That Cairns District Mental Health Service review partnerships with ambulance, police and Royal Flying Doctor Service for safe transport protocols
46. That Cairns District Mental Health Service review barriers to providing inpatient beds for Cooktown and surrounding districts
47. That consideration be given to increasing acute mental health inpatient beds at Cairns Base Hospital to five
48. That Queensland Health provide funding for adequate nursing staff numbers at Cooktown hospital and mental health worker positions
49. That Cooktown hospital be urgently refurbished/redeveloped to provide room properly configured for at-risk patients
50. That consideration be given to creating medical positions managed by regional service with fly in/fly out provision
51. That Queensland Medical Board and Royal Australian and New Zealand College of Psychiatrists streamline assessment and recognition processes for overseas trained psychiatrists
52. That Cooktown Hospital Administration review process for collection and dissemination of Queensland Health State Wide initiatives
53. That there be formal lines of reporting responsibility between mental health district staff and psychiatrists/Team Leaders in Cairns
54. That Cooktown Hospital Administration review distribution process for sentinel event review recommendations
55. That Cooktown Hospital formulate and publish orientation manual to all staff identifying local issues and procedures
56. That Queensland Health and Cooktown Hospital develop and implement policies to give effect to Sentinel Event Team recommendations
57. That Queensland Health provide funding including recurrent funding for training referred to in Sentinel Event Report
58. That Queensland Health Patient Safety Centre remain point of contact for coronial findings and recommendations
59. That Queensland Health Patient Safety Centre be mandated to provide all coronial findings and recommendations to Area Health Service Clinical Governance Units
60. That Area Health Service Clinical Governance Units effectively communicate coronial findings and recommendations to all mental health professionals