Ms D - Non-inquest findings

Contributing factors

• Failure to adequately assess and manage suicide risk despite multiple presentations
• Lack of formal safety planning despite documented suicidal ideation
• No means restriction strategy despite knowing patient was suicidal and had access to lethal medication
• Poor inter-agency communication and lack of coordinated case management
• Absence of key worker to coordinate complex multi-service care
• Inadequate refuge staffing and lack of daily monitoring protocols
• Refuge staff failure to respond appropriately to crisis call on 19 October
• Breach of patient confidentiality by hospital staff contacting patient's abuser
• Lack of suicide risk training for refuge and community staff
• Domestic violence context not adequately integrated into mental health assessment
• Inconsistent documentation including misreporting of suicide risk assessment score from medium to low
• Prescription of lethal doses of medication without coordination between prescribers
• Discharge from hospital to refuge without ensuring refuge was aware of suicide risk
• Complex social circumstances including unresolved concerns about son's safety and welfare

Coroner's recommendations

1. Develop and implement a targeted suicide prevention framework within domestic and family violence refuges accounting for detection of and response to vulnerable individuals
2. Introduce mandatory training for staff who may come into contact with victims and perpetrators of domestic and family violence
3. Establish cross-professional training and relationship building between mental health, drug and alcohol, and domestic and family violence services
4. Require specialist domestic and family violence awareness training for all registered practitioners within one year of registration with ongoing refresher training
5. Develop a mechanism for practitioners to identify persons experiencing domestic and family violence and high-risk families based on previous presentations
6. Implement real-time prescription monitoring system in Queensland at earliest opportunity
7. Ensure standardised suicide and self-harm risk screening at each intake in all service sectors
8. Establish coordinated case management with a designated key worker for complex multi-service cases
9. Incorporate formal safety planning as standard provision in mental health discharge planning
10. Consider means restriction as a standard suicide prevention strategy, including alteration to prescribing and dispensing practices
11. Implement integrated service response model with case manager/lead professional responsible for ensuring client receives right mix of services in right order at right time
12. Ensure refuge workers are aware of suicide risk and receive appropriate training and support
13. Establish protocols for regular contact and daily sighting of high-risk refuge residents
14. Develop clinical practice guidelines for social workers in relation to domestic and family violence
15. Establish Nurse Navigator positions in rural areas to work with mental health patients with complex needs
16. Ensure mental health clinicians receive training in contemporary suicide risk assessment reflecting current research evidence
17. Improve quality and consistency of clinical documentation and record-keeping
18. Strengthen inter-agency collaboration and communication strategies for managing patient suicidality
19. Develop housing assistance for women and children escaping domestic violence including expanded eligibility criteria