Justin

Contributing factors

• Bar of soap accessible in psychiatric intensive care unit
• Size of soap (100-125gm) sufficient to cause airway obstruction
• Periodic observations conducted by looking through door window rather than direct assessment
• Blanket coverage obscuring mouth and airway during observations
• Diagnostic uncertainty and change in psychiatric diagnosis without adequate trial of initial treatment
• Rapid medication changes by second psychiatrist without documented rationale or structured evaluation
• Lack of systematic environmental hazard identification process in psychiatric unit
• Complex patient presentation with multiple failed treatment trials creating clinical uncertainty

Coroner's recommendations

1. Reduce soap bar size from 100-125gm to 10-15gm to reduce risk of airway obstruction
2. Enhance periodic observations to include direct entry into rooms and listening for breathing, with documentation of clinical wellbeing features beyond simple awake/asleep status
3. Director of Mental Health in Queensland Health develop and implement a systematic Environmental Risk Management System for psychiatric intensive care units including checklists for routine hazard identification and assessment
4. Implement improved clinical review documentation framework reflecting hospital's Clinical Review Workplace Instruction with structured assessment of diagnosis, treatment, discharge planning, medication review, and special observations
5. Ensure Medical Emergency Team members have swipe card access to Acute Mental Health Unit buildings
6. Develop formal guidelines and structured processes for consultant psychiatrists changing diagnoses of previous treating clinicians, requiring explicit documentation of rationale, consideration of second opinions, and formal review meetings
7. Establish Complex Case Review Panel process for high-risk or complex psychiatric cases with structured diagnostic formulation and care planning
8. Encourage formal peer review meetings and second opinion processes, particularly when antipsychotic medications are being ceased or diagnosis is being changed from psychotic to non-psychotic disorder
9. Improve handover processes between clinicians changing psychiatric care, ensuring documented communication of diagnostic rationale and treatment plans
10. Disseminate lessons learned from this incident through Queensland Health's Chief Psychiatrist's Office to other like facilities