Coroner's Finding: STRANGWAYS Kenneth Charles

Contributing factors

• inadequate discharge planning from James Nash House
• confusion about mental health detention status after Guardianship Board hearing on 4 November 1997
• failure to admit to hospital despite clinical need
• non-compliance with anticonvulsant medication due to cognitive impairment and lack of insight
• alcohol abuse exacerbating seizure risk
• lack of appropriate secure accommodation for patients with multiple diagnoses
• service fragmentation between mental health and drug and alcohol treatment agencies
• inadequate case management after discharge
• withdrawal of Continuing Detention Order application
• cognitive impairment from prior head injuries preventing informed decision-making about treatment

Coroner's recommendations

1. The Government of South Australia should review provision of services to the mentally ill with a view to ceasing denial of care to patients based on diagnosis, providing services to those with multiple diagnoses, and providing appropriate mental health services to Aboriginal people
2. The Public Advocate should keep a written record of when detention powers granted by Section 32 of the Guardianship and Administration Act have been exercised in relation to a particular person, with relevant details, to enable quick reference by police and other workers
3. Agencies involved in secure care of mentally ill patients should review discharge planning procedures to avoid misunderstandings like those that occurred in this case
4. The Minister for Human Services should review staffing levels at the Office of the Public Advocate to ensure adequate case management and care provision given the current caseload ratios (approximately 1:150)