Coroner's Finding: KOLBIG Drew Robin

Contributing factors

• failure to implement community treatment order despite known pattern of medication non-compliance without legal compulsion
• failure to adequately assess and respond to escalating psychotic symptoms on 20 April 2011
• inadequate communication between occupational therapist and psychiatrist regarding patient's delusional paranoia
• failure to elicit suicidal ideation from patient expressing he did not want to die and hearing voices
• deferral of antipsychotic medication administration to elderly grandmother instead of supervised MAC team administration
• failure to respond to multiple requests for hospitalization on 21 April 2011
• inadequate psychiatric oversight and supervision of community mental health workers
• misinterpretation of Mental Health Act 2009 as requiring all less restrictive alternatives be attempted before community treatment order

Coroner's recommendations

1. That South Australian Mental Health Services therapists, including mental health nurses, occupational therapists and social workers, receive up to date training in identification of suicidal ideation and conduct of mental state examinations
2. That within South Australian Mental Health Services it be rendered mandatory for Mobile Assertive Care team members to immediately report to a psychiatrist actual or suspected suicidal ideation identified in a patient
3. That psychiatrists, medical practitioners and authorised health professionals be properly advised as to the legislative requirements concerning the imposition of Level 1 and Level 2 community treatment orders under the Mental Health Act 2009 and, in particular, be advised that there is no legal requirement that less restrictive means than a community treatment order or inpatient treatment order of ensuring appropriate treatment of a person's mental illness need actually be implemented before a community treatment order or inpatient treatment order can be considered
4. That within the South Australian Mental Health Services the continuity of care in respect of the identity of a treating psychiatrist should be encouraged, if not considered essential, in the treatment of a patient with mental illness