McDonnell, Kevin Joseph John

Contributing factors

• vascular dementia
• coronary atherosclerosis
• severe depression with melancholic features
• post-ECT delirium
• medication effects (olanzapine, promethazine, venlafaxine)
• confusion and disorientation
• decreased observation frequency due to documentation error
• lack of psychiatric review for 48 hours due to staff absence
• unlocked ward with unrestricted patient access

Coroner's recommendations

1. Future versions of patient physical observations forms should include information regarding the patient's recommended observation regime as clinically specified by the treating team
2. Observation sheets should indicate whether patients are restricted to the ward or able to leave and for what periods
3. Implement an education program to address issues relating to poor documentation of absconding incidents and clinical decision-making
4. Redesign PICU weekend planning documentation to include information on which clinicians were present at meetings and which ward was being discussed
5. Develop a process ensuring all new Friday admissions to mental health inpatient units who are not seen by their treating team are reviewed by a psychiatry registrar over the weekend
6. Establish a system to ensure inpatients on visual observations are reviewed by a substitute psychiatry medical officer when their treating team is unexpectedly absent due to sick leave
7. Review the visual observations process to determine when the number of patients on observations becomes unmanageable/unsafe and requires escalation
8. Update visual observations documentation to clearly state whether the ward was locked and to indicate specific visual observation orders currently in effect