Coolwell, Bradley Karl

Contributing factors

• premature transfer to mental health ward despite serious respiratory compromise
• failure to act on critical blood gas results indicating hypoxemia and hypercarbia
• lack of clear communication between medical and mental health teams
• absence of specialist respiratory support in mental health environment
• physical restraint during seclusion process in setting of respiratory illness
• obesity and pre-existing chest infection contributing to respiratory vulnerability
• hypoxic event following midazolam administration

Coroner's recommendations

1. Review and optimize the CIMHA system to provide information summarizing mental health history of patients subject to Involuntary Treatment Orders, to assist practitioners making subsequent Emergency Examination Orders
2. Make CIMHA system available to police on a read-only basis
3. Implement admission policy based on consultant-to-consultant or director-to-director discussion to reach agreement on most appropriate department for patient admission
4. Review admission processes and patient flow within Integrated Mental Health Service during business hours and after-hours including linkages between acute services and Community Mental Health
5. Continue work with Queensland Psychotropic Medication Advisory Committee to develop Acute Sedation Guidelines with arrangements between ED, ICU and IMHS to ensure better alignment
6. Establish mental health clinical position in ED, being a senior nurse to provide guidance to junior staff, particularly for patients admitted to Short Stay Unit
7. Implement metabolic monitoring in Community Mental Health and mental health inpatient settings
8. Implement process of auditing adherence to metabolic monitoring guidelines
9. Clarify definition of 'medical clearance' including indication of level of support patient will need on admission
10. Review case management practices to ensure culturally appropriate recovery focus
11. Implement process of operational supervision to ensure case managers apply contemporary case management strategies