Patient A

Contributing factors

• Decision to treat in community rather than admit to hospital despite partner's repeated requests
• Persistent suicidal ideation not adequately addressed
• Inadequate response to treatment failure - patient showing limited response to sertraline
• Limited clinical documentation of decision-making rationale
• Lack of documented clinical review following initial assessment
• Delayed medication adjustments
• Poor communication with family regarding clinical decision-making
• Inadequate Root Cause Analysis process

Coroner's recommendations

1. Root Cause Analysis processes should ensure that relevant members of the treating team are provided an opportunity to be interviewed and are provided with feedback as to the outcome of the RCA
2. Mental health services should improve clinical documentation to clearly articulate consideration of mental state and risk assessment, outcomes of clinical review, management and treatment plans, and inclusion of family and significant others in care planning
3. Communication with families and carers regarding clinical decision-making for community versus hospital treatment should be more specific and collaborative
4. Open disclosure processes should be conducted by trained personnel with sufficient knowledge of the treatment case to provide answers to family members
5. More timely and appropriate response from senior management and clinical staff following tragic incidents