Cuttler, Melina Maree

Contributing factors

• Unassessed acute psychosis
• Failure to assess patient within recommended 30-minute timeframe for Category 3 triage
• Mental health clinical nurse referred to ATODS without conducting initial assessment
• Lack of mental health assessment rooms in ED
• No escalation process when ATODS assessment identified psychotic symptoms
• Psychiatric registrar not involved in assessment despite identified psychosis
• No medical officer examination of patient despite 4.5 hours in ED
• Inadequate communication between ED and mental health teams
• Lack of leadership and escalation when family requested assistance
• Insufficient staffing and infrastructure in ED to manage mental health presentations
• Failure to actively intervene when patient left ED and family raised safety concerns
• Complacency due to patient appearing jovial at times and presence of two support persons
• Clinical Nurse Consultant located on different floor, hindering communication

Coroner's recommendations

1. Further education for ED clinicians on use of ED Mental Health Triage Assessment and Management Tool
2. DEM Mental Health Clinician to liaise with ED SMO/Shift Coordinator after triage of mental health presentations to confirm risk management guidelines and document safety plan
3. Develop formal process for written and verbal handover of assessment outcomes from external consultations to Medical Officer in charge
4. Formalise Rapid Assessment Team review process with work instruction ensuring patients exceeding recommended Category 3 treatment time receive timely review
5. Update ED Work Instruction for rounding in waiting room to include clear escalation matrix and documentation of observations and interventions
6. Develop internal escalation process for when triage staff or relatives raise concerns about patient presentation
7. Provide education on legal aspects of care in ED including duty of care, Mental Health Act, and Guardianship and Administration Act
8. Consider structure of Department of Emergency Mental Health Team at Ipswich Hospital and whether leadership should include direct psychiatric input