KLUMPER Joshua William

Contributing factors

• Cannabis withdrawal
• Workplace stress related to employment loss due to cannabis use
• History of self-harm and suicidal ideation
• History of multiple suicide attempts
• ADHD
• Oppositional Defiant Disorder
• Poor medication compliance
• Difficulty engaging with mental health services
• Lack of formal transfer-of-care plan when transitioning from CYMHS to private care

Coroner's recommendations

1. MHSS consider a project to review the literature regarding compassion in healthcare and use this to inform an action plan
2. Community CYMHS teams introduce a process for direct engagement with consumers aged 16 years and older, in addition to contact with the consumer's next of kin
3. Community CYMHS teams review their processes to ensure ongoing proactive response to difficult to engage consumers
4. Clarify the role of the Clinical Team Coordinator as part of the HHS 'Code Black – Personal or Facility Threat' Procedure
5. Development and implementation of refresher training for the Acute Care Team focused on advanced crisis assessment and intervention skills with reference to age-specific cohorts and consumers with developmental conditions such as ASD
6. Future environmental reviews of the ED to account for strategies to address sensory overload concerns for consumers with developmental conditions