Van Putten, Patricia

Contributing factors

• Complex comorbid Major Depressive Disorder and Borderline Personality Disorder
• Breach of discharge supervision plan by Mr Lowe-Brock leaving patient unattended
• Inadequate verification of Mr Lowe-Brock's suitability as lay supervisor; undetected mental health issues
• Lack of written communication between hospital psychiatrists and long-term private GP
• Inadequate documentation standards for risk assessment and clinical reasoning
• Limited access to intensive psychotherapy in the Far North Queensland region
• Patient's resistance to involuntary admission and institutional care
• Insufficient after-hours mental health coverage and bed availability

Coroner's recommendations

1. Urgent funding for Cairns Acute Care Team to expand clinical cover to 24 hours a day, 7 days a week
2. Increase capacity of rural mental health teams to facilitate best practice case management and follow-up care by adding clinical positions to Innisfail and Tablelands community Mental Health Teams
3. Queensland Health to continue developing and implementing a competency-based training module on Clinical Documentation Standards for mental health and primary health staff
4. CIMHS to introduce a training package with competency-based assessment for all clinicians in acute mental health services covering history taking, mental state examination, provisional diagnosis, risk assessment and initial management planning
5. Enhancement of CIMHS internal audit system to conduct regular clinical audits in all services including rural teams
6. Queensland Health to immediately cease the practice of requesting patients with mental health issues to guarantee their own safety
7. Accelerate implementation of a state-wide electronic network of patient information allowing treating health professionals rapid access to patient data throughout the State
8. Establish regular formal minuted meetings between public and private sector medical staff to facilitate discussion of problems and generate workable action plans
9. CIMHS to receive funding to implement the 'Partners in Mind' primary mental health care framework to improve referral pathways between public and private systems
10. State-wide development and implementation of a family-focussed model of care recognising importance of family and carers' views in developing care plans, underpinned by policy statements, clinical guidelines and competency-based training
11. Medium to high risk mental health patients should only be supervised by family members or friends when clinicians are satisfied the lay carers have capacity to provide appropriate supervision, are properly informed of risks, and have adequate information about when and who to contact for assistance
12. Queensland Health to review Health Services Act 1991 provisions relating to disclosure of confidential information to balance patient confidentiality with duty of care and rights of carers
13. Queensland Health to develop, implement and provide training in state-wide guidelines defining issues of confidentiality in mental health and circumstances appropriate for information sharing
14. Remove requirement in s62I Health Services Act to have chief executive written authority for disclosure of confidential information necessary to avert serious risk to life, health or safety
15. Queensland Government to increase funding to community-based services to assist adults with mental health problems in the Cairns area, including clinical and non-clinical services, nursing, allied health, psychiatrists and indigenous mental health workers
16. Queensland Health to invest in programs of intensive post-discharge support for patients presenting with suicidal ideation or assessed at risk of suicide or self-harm in the Cairns District Health Service Area