Coroner's Finding: FOOT Brodie Sian

Contributing factors

• failure to refer patient to psychiatric registrar despite first-time presentation with suicidal ideation
• provision of diazepam without medical practitioner assessment
• fragmented care with four different healthcare providers on same day
• failure to maintain continuity of care with referring practitioner
• mental health nurse recommendation of different general practitioner instead of referring GP
• inadequate documentation of medication dispensed
• insufficient assessment of psychiatric symptoms and suicide risk
• lack of clear policies or protocols regarding psychiatric assessment in emergency department

Coroner's recommendations

1. Implement clear written guidelines for ACIS nurses and psychiatric staff regarding assessment and referral protocols in the Emergency Department
2. Ensure all patients presenting with specific psychiatric problems such as depression and suicidal ideation are referred to a psychiatrist for review
3. Establish that no psychotropic medication should be provided without review by a medical practitioner
4. Provide proper orientation and training for mental health nurses working in the Emergency Department, particularly regarding departmental policies
5. Develop a system to ensure continuity of care with the referring practitioner rather than recommending alternative practitioners
6. Implement a policy that patients should not be passed between multiple providers on the same day without assuming continuing responsibility
7. Establish clearer documentation requirements for medication dispensed to patients