Coroner's Finding: MCKENZIE Deborah Francis

Contributing factors

• inadequate mental health assessment on discharge from hospital
• failure to detain under Mental Health Act 2009
• failure to obtain collateral information from family
• failure of medical practitioner to examine patient before discharge
• premature hospital discharge
• failure to communicate between medical practitioners
• miscarriage of bail procedures allowing accused individuals to be released
• failure of police to know of patient's hospitalisation
• lack of early intervention by family violence investigation section
• alcohol consumption the night of death
• guilt over reporting ex-partner to police
• concern about effect on son
• release on bail of three individuals she had informed against

Coroner's recommendations

1. Establish dedicated, properly staffed psychiatric unit in Port Augusta region with at least one full-time permanent consultant psychiatrist and psychiatric registrar, designated as approved treatment centre under Mental Health Act 2009
2. Instruct all clinicians at regional hospitals to use tele-psychiatry services (Rural and Remote Triage Service) for all patients suspected of suicide risk or actual suicide attempts
3. No patient suspected of suicide risk or having made suicide attempt should be discharged from regional hospital without medical practitioner review; psychiatrist input (in person or remote) should be sought for any proposed discharge
4. Maintain continuity of care for at-risk patients; proper in-person handovers between medical practitioners; ideally same practitioner maintains care
5. Reinforce need to gather collateral and corroborative information from family/carers before discharge of at-risk patients
6. Clinicians should assess with critical mind patient denials of suicidal intent, considering possibility denials are motivated by desire for discharge; evaluate denials of previous suicide attempts against documented medical history
7. Port Augusta Hospital review prescription practices for olanzapine, particularly avoiding use where: no psychosis evident, overdose of other medication occurred, mental health assessment needed with olanzapine effects present, or more suitable alternatives available
8. Commissioner of Police develop domestic violence protocol for cases where complainant is also informant against domestic partner, addressing witness protection, welfare, bail, and ensuring police kept informed of victim's medical issues in high-risk cases
9. Commissioner ensure police prosecutors fully aware of duties regarding bail; educate on section 10A Bail Act 1985 and enlivening offences; ensure DPP advice is read, understood and strictly adhered to; consider Supreme Court bail review as default position when bail strongly opposed
10. Commissioner ensure investigating/arresting officer or properly briefed nominee attends court for opposed bail applications in serious crime cases
11. Commissioner ensure prosecution units in Port Augusta/Whyalla properly staffed with well-briefed prosecutors
12. Commissioner ensure investigating officers aware of need to protect vulnerable witnesses and ensure they are informed of hospitalisation of such witnesses, especially mental health hospitalisations
13. Request to Minister for Health and Minister for Aboriginal Affairs: establishment of halfway house/psychiatric institution for young Aboriginal people in similar situations, named in Ms McKenzie's honour