Vaggs, Lyji

Contributing factors

• prolonged prone restraint (>30 minutes)
• rapid administration of olanzapine in violation of guidelines (two 10mg doses 10 minutes apart when guidelines require 2-hour intervals)
• administration of midazolam during active restraint
• synergistic respiratory depressant effects of olanzapine and midazolam
• patient obesity reducing respiratory capacity during prone restraint
• failure to admit on 28 March 2010 despite clear indication
• inadequate psychiatric assessment and follow-up between 28 March and 12 April
• failure to admit on 12 April 2010 despite continued symptoms and partner's inability to cope
• absence of senior psychiatrist supervision during restraint and medication administration
• lack of leadership during restraint by medical or nursing staff
• no family member present to calm patient
• poor communication between ED and mental health intake team
• limited access to prior medical records from Hughenden Hospital
• failure to recognise severity of presentation on 13 April before arrival at hospital
• figure-4 leg lock further compromising respiration
• handcuffs applied after restraint prolonged rather than used earlier to shorten duration

Coroner's recommendations

1. Development of Triage Assessment Record for patients with mental health presentations to improve information transfer from ED to mental health intake teams
2. ED notes to be incorporated into mental health assessments uploaded to CIMHA
3. Improved training and changes to assessment procedures and documentation for ED mental health assessments
4. Psychiatric case review at daily CATT morning meetings with robust follow-up processes
5. Urgent psychiatric review to be arranged within 24 hours when recommended
6. Improved access to inter-hospital medical records, particularly regarding recent presentations to other facilities
7. Recall and engagement of family members/support persons in mental health assessments to obtain collateral information
8. Involvement of family members or support persons during hospital admission process
9. Implementation of Behavioural Emergency Management training program for all staff
10. Review and reinforcement of procedures for duress responses with clear designation of senior nurse as default leader of restraint
11. Implementation of restraint and seclusion checklist to maintain awareness of restraint risks
12. Implementation of early warning system to alert staff to signs of patient deterioration during restraint
13. Implementation of safer behavioural emergency management program based on Canberra Hospital model
14. Increase in number of consultant psychiatrists in AMHU to ensure 24-hour coverage
15. Transfer of outreach service responsibility to separate team with dedicated consultant
16. Additional training places for psychiatric registrars
17. Review of on-call arrangements to ensure senior psychiatric support available
18. Increased compliance with rapid sedation guidelines through laminated cards with guidelines attached to staff lanyards
19. Recommendation 1: Director of Mental Health to review whether flexible plastic wrist ties or hinged handcuffs should be approved for use in restraining violent mental health patients (in preference to soft wrist cuffs linked to waist band currently approved)
20. Increased recruitment and training of Aboriginal and Torres Strait Islander mental health workers to be involved in all parts of mental health service including AMHU and acute care teams
21. Requirement that all restraint and seclusion incidents be entered on CIMHA for measurement and monitoring