Follent, Mitchell James - Non-inquest findings

Contributing factors

• Inadequate risk assessment despite multiple static risk factors
• Deficient discharge planning and coordination
• Failure to involve primary carer (mother) in discharge planning
• Lack of comprehensive medical and neurological assessment for organic causes
• No functional assessment despite inability to self-care
• Absence of follow-up mental health services post-discharge
• Medication non-compliance post-discharge
• Cannabis use post-discharge
• No contact with disability support services for collateral information
• Possible post-ictal psychosis, drug-induced psychosis, or cannabis-related psychosis at time of death

Coroner's recommendations

1. Mental Health Unit to develop process ensuring comprehensive multidisciplinary discharge plan is developed and documented for all presentations, particularly those with complexity, involving all relevant stakeholders including patient, carers, mental health service, and Acute Care Team where referrals are made
2. Mental Health Unit to develop process ensuring completion of Consumer Care Review Summary, Consumer End of Care/Discharge Summary, Recovery Plan, Family Support Plan, Personal Safety Plan, follow-up appointments, and copies of relevant documents to key stakeholders are completed at point of discharge
3. Formal neurological assessment should be undertaken for presentations where organic causes may contribute to altered mental state
4. Clinical incident reporting processes to be strengthened, particularly for episodes of physical restraint
5. Falls assessment and management plans to be completed for all fall events
6. Risk assessment to be comprehensive, documented, and include static, dynamic and protective factors with corresponding management plan
7. Functional assessments by occupational therapy to inform discharge support requirements
8. Enhanced communication with family members and disability support services during discharge planning
9. Verification of patient capacity to manage own medication prior to discharge
10. Timely follow-up by Acute Care Team post-discharge, particularly for first episode psychosis with new antipsychotic medication
11. Timely forwarding of discharge summary to GP with specific advice on management of psychosis and new medications
12. Formal revocation of Involuntary Treatment Orders prior to discharge