Coroner's Finding: MIDDLETON Geraldine Ruth

Contributing factors

• failure to conduct and document adequate mental state examination in ED
• failure to recognize high-intent self-harm behaviour
• failure to detect active psychosis (auditory hallucinations)
• failure to appreciate suicide risk despite extensive scarring and recent serious self-harm
• failure to detain patient under Mental Health Act despite clear indications
• inadequate assessment by ACIS team 15 hours after initial presentation
• poor documentation by both ED and ACIS of mental state findings
• failure to escalate care after second self-harming episode
• separate medical records between hospital and ACIS preventing continuity of care
• lack of clear protocols and guidelines for ED staff managing acute psychiatric presentations
• inadequate communication between services

Coroner's recommendations

1. Develop protocols for ED medical staff clarifying available resources, powers under Mental Health Act, and guidance for appropriate interaction with ACIS and other mental health services
2. Develop checklists to assist medical staff and ACIS team members to perform adequate mental state examinations in patients with suspected mental illness
3. Remind medical practitioners and ACIS staff of the need to properly document mental state examinations in medical records
4. Examine ways for Mental Health Services and public hospitals to provide staff access to combined medical records when both services are involved in patient treatment