Coroner's Finding: BALL Norman Samual Dean

Contributing factors

• inadequate discharge planning from psychiatric hospital
• failure to notify general practitioner of discharge
• no discharge summary prepared
• no community mental health follow-up arranged
• bed pressure and resource constraints
• administrative gaps due to absent ward clerk
• organic brain damage from previous head injury
• recent court case acquitting assailant (loss and disappointment)
• social stressors over Christmas period
• subtherapeutic medication levels due to toxic citalopram levels
• long history of depression, impulsivity and self-destructive behaviour
• unemployment and social isolation

Coroner's recommendations

1. Ensure discharge planning systems are in place for all psychiatric patients, particularly those at high suicide risk
2. Establish mandatory procedures to notify the general practitioner before discharge of high-risk psychiatric patients
3. Implement discharge checklists and administrative procedures to prevent lapses in communication
4. Ensure adequate administrative support is maintained during holiday periods
5. Establish clear communication protocols between multiple treating doctors (e.g. Dr A. and Dr S.)
6. Ensure involvement of community mental health services (ACIS) for vulnerable discharged patients
7. Consider provision of on-call psychiatric registrar coverage after-hours to improve quality of assessment and planning