Harris, Robert

Contributing factors

• suicide note not conveyed to assessing psychiatrist
• isolated location of suicide attempt not communicated to treating doctors
• inadequate collateral information from police
• critical information obtained by ambulance/police not systematically passed to hospital staff
• discharge decision made by trainee registrar without direct consultant psychiatrist involvement
• family not adequately informed of risks or included in discharge plan
• follow-up assessment on 28 June conducted by nursing staff without psychiatrist review despite significant clinical dispute about diagnosis and risk
• lack of 24-hour mental health presence in Emergency Department
• Emergency Department overcrowding and bed shortages
• confidentiality protocols preventing timely information sharing with police on 28 June
• inadequate documentation and delayed clinical note writing
• reliance on patient assurances of safety without adequate risk assessment
• first presentation with depression and two suicide attempts within one month not escalated appropriately

Coroner's recommendations

1. Queensland Health develop and implement competency-based training modules on clinical documentation standards, risk assessment, mental state examination, and Mental Health First Aid for CIMHS and primary health staff
2. CIMHS introduce training packages with competency-based assessment for clinicians in acute mental health services covering history taking, mental state examination, provisional diagnosis, and risk assessment
3. Enhancement of CIMHS internal audit system for regular clinical audits across all services
4. Redesign of Cairns Base Hospital Emergency Department to provide better assessment and treatment environment for mental health patients
5. Urgent funding for Cairns ACT team to expand 24/7 clinical cover to Emergency Department and community
6. Fund creation of second ACT Psychiatry Registrar position to provide timely psychiatric treatment and reduce after-hours burden
7. Ensure all ED clinical staff aware of Queensland Health guidelines for management of people with suicidal behaviour
8. Queensland Health immediately cease requesting patients with mental health issues to guarantee their own safety
9. CIMHS introduce system for consultant psychiatrist review of all separations from ED, including adequacy of history, mental state assessment, risk assessment, and management plans
10. Two mental health workers should complete mental health risk assessments where possible, with consultant psychiatrist review of any disagreements
11. Queensland Health amend Guidelines for management of patients with suicidal behaviour to require consultant psychiatrist review where clinicians dispute risk assessment
12. CIMHS allocate a consultant psychiatrist to supervise each mental health patient's management for consistency and clear communication point for families
13. CIMHS consider requiring direct involvement of consultant psychiatrists in assessment of patients over 50 presenting for first time with depression, particularly with first suicide attempt
14. Continue planning and funding to increase mental health inpatient beds at Cairns Base Hospital
15. Queensland Health Patient Safety Unit and Director of Mental Health follow up recommendation that coronial findings into mental health patient deaths be summarized and distributed regularly to district mental health leaders
16. Director of Mental Health accelerate implementation of state-wide electronic patient information network allowing rapid access to patient data across health professionals and agencies
17. Establish regular formal minuted meetings between public and private sector medical staff to discuss problems and develop action plans
18. CIMHS receive funding to implement Partners in Mind primary mental health care framework
19. State-wide development and implementation of family-focused model of care with policy, guidelines and competency-based training, including provision of information to families about mental health illness
20. Medium to high risk mental health patients should only be under family/friend supervision when clinicians satisfied family has capacity, is properly informed of risks, and has adequate information about when and who to contact
21. Queensland Health continue reviewing Health Services Act provisions on confidentiality disclosure and implement changes to balance confidentiality with duty of care and public protection
22. Queensland Health develop and provide training in state-wide guidelines to mental health workers defining confidentiality issues and circumstances for appropriate information sharing
23. Remove requirement in section 62I Health Services Act requiring written chief executive authority for disclosure of confidential information necessary to avert serious risk to life, health or safety (note: section has been amended since Robert's death with delegable authority now in place in Cairns)
24. Queensland Government increase funding to community-based services for mental health support in Cairns including clinical and non-clinical services, generic and specific services
25. Queensland Health invest in intensive post-discharge support programs for patients assessed at suicide risk or with suicidal ideation in Cairns District Health Service Area
26. Queensland Police Service provide written summary of circumstances and collateral information when presenting mental health patients to hospital ED, including details of suicide attempts, means, medications, witness information, suicide notes, and family contact details
27. Cairns Base Hospital ED reinstate lines of communication with Queensland Police Service for better working relationship and timely information exchange, with Executive Director of Medical Services making liaison meetings responsibility of Director of Emergency Medicine
28. Queensland Police Service introduce policy for disclosure of suicide notes to families (subject to confidentiality and ongoing investigations)
29. Queensland Police Service introduce policy to seize all items suspected of being used in suicide attempts for safety reasons