Henderson, Robert Joseph

Contributing factors

• patient absconded from psychiatric ward before psychiatric review
• delay in psychiatric assessment on admission to hospital
• patient had accessed drugs other than those prescribed
• patient subject to involuntary treatment order with known history of non-compliance
• incomplete medical records and documentation
• no bed available in acute observation area
• patient had history of substance abuse and mental illness (schizophrenia)
• acute bronchopneumonia from aspiration of vomitus

Coroner's recommendations

1. Review of training and/or supervision of team members by the team leader regarding proper completion of risk assessment documentation
2. Implementation of electronic medical records accessible by all staff (both hospital and community) to maximise access to timely, complete and correct information
3. Improvement of record keeping practices, particularly in multi-disciplinary mental health treatment teams with volatile patients requiring constant review
4. Proper documentation of all prescription medication dispensation, particularly for patients with history of drug abuse, to avoid inappropriate stock-piling and ensure all team members have complete information
5. Police attending scenes of suspected drug-related deaths should conduct thorough investigation and documentation, including detailed recording of all medications and drug paraphernalia, and take comprehensive photographs at the scene