SHARMA, Manmeet

Contributing factors

• Discharge from mental health service without adequate discharge planning or GP involvement
• Failure to transfer 2012 Community Forensic Outreach Service recommendations when patient transitioned to Metro South Health in 2012
• Risk assessments based on current presentation rather than longitudinal history and persistent violent ideation
• Lack of communication with general practitioner due to patient refusal and inadequate override protocols
• Discontinuation of involuntary treatment order in December 2014 based on incomplete information about medication compliance
• Patient not taking oral antipsychotic medication for extended periods prior to discharge
• Failure to adequately respond to patient's attempt to re-engage with services on 31 August 2016
• Lack of comprehensive forensic assessment despite multiple referrals to Community Forensic Outreach Service
• Social isolation and absence of community supports at time of discharge

Coroner's recommendations

1. Queensland Health to consider creating a project with relevant stakeholders to determine how to create, facilitate and support links between public and private mental health sectors for patients requiring long-term therapeutic engagement, to ensure continuity of care during transition
2. Continue implementation of comprehensive care processes to improve shared care between providers across public, private and non-government sectors
3. Continue evidence-informed implementation of Comprehensive Care initiative with focus on stepped care linkages and longitudinal sharing of risk-related information