Coroner's Finding: POTTER Claire Elizabeth

Contributing factors

• inadequate psychiatric assessment and monitoring during Royal Adelaide Hospital admission
• no psychiatric review for over 24 hours prior to transfer between campuses
• transfer authorised without personal assessment of patient by responsible psychiatrist
• unclear medication administration records despite critical importance for non-compliant patient
• placement in open ward despite documented history of absconding
• late-afternoon transfer timing reducing resource availability for admission assessment
• insufficient supervision during admission procedures at Glenside Hospital
• loss of clinical documentation during inter-campus transfer
• inadequate hand-over between nursing staff at time of transfer

Coroner's recommendations

1. The Director, Mental Health Services, should review the Hospital Support Team system at the Adelaide and Glenside Campuses to ensure: (1) patients are adequately supervised and regularly assessed by qualified clinicians; (2) even for inter-campus transfers, adequate transfer planning occurs and patient mental state is assessed prior to transfer; (3) further consideration be given to loss of information during inter-campus medical records transfer; (4) adequate medication records are kept so clinicians know what medications have been administered and when
2. Detained patients transferred to acute inpatient mental health beds should be observed 15-minutely for minimum 2 hours then reassessed for risk level
3. Risk Assessment Form should be revised to explicitly comment on risk of absconding and impulsivity and link these to nursing observation category
4. Royal Adelaide Hospital should consider feasibility of having own ambulance(s) for timely patient transfer
5. Royal Adelaide Hospital should amalgamate all medical records and documentation across campuses
6. Mental health patients transferring to Glenside Campus should have medications written up on mental health medication chart prior to transfer