Huntington, Sparka Isarva aka Huntington, James Philip

Contributing factors

• Failure to place patient in secure custody despite forensic order and history of absconding
• Patient admitted to open ward on 6 December despite previous abscondings
• Inadequate access to community mental health records during out-of-hours presentation
• Junior inexperienced registrar unable to obtain senior psychiatric support
• Patient seriously sexually assaulted another patient and absconded again
• Untrained security officers lacked restraint certification and training
• Prolonged physical struggle lasting over 35 minutes
• Patient held face-down in garden bed for extended period
• Inadequate medication dosing protocols (40 mg Zuclopenthixol instead of usual 200 mg)
• Refusal to give Diazepam/sedatives during escalating crisis
• Patient aspirated vomit and had face pressed into garden bed
• Severe pre-existing coronary artery disease (90% blockage)

Coroner's recommendations

1. Recommendation 1 - Adequate access to mental health records: Queensland Health should develop an electronic database to enable clinicians to instantly access medical records of mental health patients who have been treated at any public health service throughout the state.
2. Recommendation 2 – Secure custody for forensic order patients: The Director of Mental Health should mandate a policy that stipulates that patients on forensic orders who abscond are automatically held in high-secure or medium-secure wards when they are returned to the responsible mental health facility until their risk of further flight can be assessed.
3. Recommendation 3 – Aggressive behaviour training and credentialing of PSOs: All mental health nursing staff and any security officers who may be called on to assist them should undertake the aggressive behaviour management course or any other more appropriate course the department chooses to develop. The holding of an appropriate competency-based qualification should be a pre-condition to employment as a security officer in a hospital.
4. Recommendation 4 – Evaluation of soft restraints: Queensland Health should evaluate the use of soft ties to assist in restraining violent patients.