Coroner's Finding: ROSS Chrystal Jessica

Contributing factors

• failure to escalate to specialist psychiatric care despite clinical indicators
• severe miscommunication between psychiatrist and bed coordinator regarding need for admission
• erroneous removal of patient from inpatient psychiatric bed waiting list without consulting treating psychiatrist
• discharge information conveyed by nurse who had never previously met the patient
• lack of proper mental state examination before discharge decision
• failure to recognise and appropriately manage patient's fear of abandonment
• inadequate community mental health team liaison and follow-up
• scarcity of mental health inpatient beds leading to system dysfunction
• patient's untreated borderline personality traits and active self-harm behaviours
• Workcover complications impeding access to appropriate mental health treatment

Coroner's recommendations

1. The number of mental health beds in South Australia should be radically increased, to a minimum of four-fold the current number, directed to the Minister for Health and Wellbeing
2. Government should provide funding through the Legal Services Commission to enable families to be legally represented in all Inquests, directed to the Attorney-General
3. No patient's name shall be removed from an inpatient mental health bed waiting list unless that decision has been reviewed by the requesting psychiatrist, the Emergency Triage and Liaison Service consultant, or the Clinical Director (this policy has since been implemented by Country Health SA)