SH and AW

Contributing factors

• Inadequate response to suicide threat on day of death
• Failure to assess or escalate despite clinical deterioration postpartum
• Medication change without follow-up review
• Recent motherhood separation and changed discharge plans
• Frequent absconding from open ward despite leave restrictions
• Psychotic symptoms on day of death not addressed
• Failure to conduct risk assessment
• Poor communication between medical and nursing staff regarding clinical concerns
• Unsuitable facility for long-term psychiatric care

Coroner's recommendations

1. Metro South Mental Health Services to communicate with Chief Psychiatrist regarding current missing consumer policy and undertake review of procedures for implementing this policy with particular reference to strategies for managing repeat absconders, no smoking procedures, and escalation processes
2. Conduct three-month trial of leave book/register to be signed by each patient leaving ward to assess whether this modifies patient behaviour and staff capacity to monitor missing persons procedure
3. Undertake review into possible technological aids to assist staff in managing repeat absconders in open ward environment (intermediate supervision between AOA/constant observations and open ward)
4. Continue clinical transformation process committed to development and implementation of strategies to identify and manage deteriorating patients with respect to mental and physical health; report expected early 2013
5. Implement journey board system providing online details of patient admission status, expected discharge date, Mental Health Act status, and visual observation frequency; pending implementation, utilize photographic identification process for patients connected to handover sheet including leave entitlements
6. Ensure scheduled MHRT reviews are entered on whiteboard system and ultimately on proposed journey board
7. Review practicality of providing reception staff with copy of visual observation photo board to identify which patients can or cannot leave ward
8. Ensure specific individual behavioural management plans for excessive alcohol and drug use by patients who cannot be discharged, including structured program of searches, regular breathalysing, and limiting access to money where legally entitled
9. Seek agreement by MOU or similar between Metro South Health Services and Mater Hospital concerning management of female psychiatric patients giving birth to promote mothers staying with baby for reasonable period after birth
10. During Queensland Health's 2013 review of Mental Health Mortality Report, review practical and legal implications for inclusion of written statements from medical and nursing staff caring for patient at time of death to assist RCA process and subsequent investigations
11. Queensland Government to progress Stage 2 of Mental Health Plan to provide Medium Secure Unit for Metro South Mental Health Services
12. Queensland Government to progress Stage 2 of Mental Health Plan to include development of Specialised Mother and Infant Unit for public psychiatric patients
13. Limson Investments Pty Ltd to install appropriate barriers to Buranda car park to prevent future suicides