Coroner's Finding: KAY Damian

Contributing factors

• Inadequate psychiatric risk assessment in Emergency Department
• Failure to read and review suicide note despite awareness of its existence
• Failure to obtain collateral history including prior suicide attempt
• Lack of consultation with senior medical colleagues
• Failure to utilise available mental health nursing support
• Failure to arrange follow-up care or crisis response
• Recent relationship breakdown and infidelity
• Unresolved grief from loss of wife and children in bushfire
• Alcohol consumption and dependence
• Recent cessation of antidepressant medication
• Previous suicide attempt via overdose 8 months prior to psychiatrist consultation

Coroner's recommendations

1. Department of Health should ensure that training in the assessment of suicidal risk should be provided both to medical undergraduates and to doctors working in Emergency Departments
2. A junior doctor or a mental health nurse should not discharge a suicidal patient, particularly one brought in by police under section 57(1)(c) of the Mental Health Act 2009, from an Emergency Department without having sought advice from a senior medical colleague - either an Emergency Department senior registrar or consultant, or a psychiatric registrar or consultant on-call
3. A minimum set of information should be obtained before discharging a suicidal patient from the Emergency Department, with information obtained from family members and current treatment doctors or other therapists where possible
4. There should be assertive follow-up of suicidal patients offered by community mental health services with expectations about timely face to face follow-up and routine offering of follow-up with community mental health teams being assertive and persistent in attempts to see patients face to face
5. SAPOL to include in annual Incident Management and Operational Safety Training (IMOST) the need to volunteer the best form of information available (such as suicide notes) to medical authorities making Mental Health Detention assessments