Coroner's Finding: NOAKES Geoffrey Scott

Contributing factors

• premature revocation of Mental Health Act detention order
• inadequate psychiatric assessment by Dr L.
• failure to obtain collateral information from general practitioner and family
• incomplete risk assessment documentation
• inadequate consideration of stated suicide plan involving rope
• undue weight given to patient denials of suicidal intent
• failure to verify accommodation arrangements
• insufficient inquiry about patient circumstances and stressors
• examination conducted without proper preparation and collateral information
• time pressures on examining psychiatrist

Coroner's recommendations

1. Psychiatrists conducting section 21(5) Mental Health Act examinations should regard these as exercises designed to achieve best therapeutic outcomes, not merely statutory requirements
2. Detailed explanation of examination purpose need not be provided to detained patients and may be undesirable in some circumstances
3. Strict DSM-IV diagnosis is not necessarily determinative for confirming inpatient treatment orders
4. Examinations should be conducted at clinically appropriate times, not scheduled to suit psychiatrist convenience, and should not occur until all collateral information is gathered
5. If examination cannot occur within 24 hours, this should be explicitly documented; revocation should not occur merely because 24 hours has elapsed
6. Section 21(5) examinations should not proceed until Initial Mental Health Assessment Clinical Record is completed and mental health staff have conducted prior assessment interview
7. The detaining medical practitioner must be consulted before any revocation decision
8. Due enquiry must be made about accommodation and support arrangements before discharge
9. Psychiatrists must critically assess patient denials of suicidal intent in context of previous statements and plans, recognising that denials may be motivated by desire for release
10. All prior acknowledgements of suicidal ideation and intent by patients should be recorded in clinical records
11. South Australian Guidelines for Working with the Suicidal Person should be re-promulgated with mandatory training to all mental health providers
12. Guidelines should include de-identified scenario based on Mr Noakes' case and specific section on section 21(5) Mental Health Act examinations
13. Mental health services should implement formal collateral information gathering procedures as standard practice rather than optional based on workload