Coroner's Finding: Papageorgiou, Theo Nickolas

Contributing factors

• premature revocation of involuntary treatment order without adequate psychiatric review
• erroneous diagnosis of first episode psychosis rather than relapsed psychosis with possible bipolar disorder
• failure to obtain and utilise longitudinal psychiatric history
• inadequate collateral information gathering from family
• poor communication between emergency department, psychiatry, community mental health teams and general practitioners
• absence of psychiatrist review at critical presentations on 14 and 17 January 2016
• failure to recognise clinical deterioration and severe depression
• superficial cross-sectional assessments without longitudinal perspective
• lack of continuity of care and absence of identified primary clinician
• inadequate medication management with failure to consider mood stabilisation
• therapeutic relationship not established during inpatient admission due to parental presence and staff inability to engage

Coroner's recommendations

1. SA Health continue implementing Chief Psychiatrist recommendations with modification that emphasis be placed on continuing professional development of rural GPs in mental health rather than credentialing
2. Conduct comprehensive review of clinical resources in mental health services in all rural regions
3. Community Mental Health Teams in regional areas be staffed by resident team consultant psychiatrist and resident psychiatric registrar with appropriate incentivisation
4. Ensure continuity of care in mental health management in regional areas
5. Hospitals in regional areas administering mental health services be provided ability and resources to administer level 2 Inpatient Treatment Orders
6. Psychiatrists and practitioners in rural areas be advised to avoid purely cross-sectional analyses and instead examine longitudinal history of patients
7. Practitioners gather collateral information from family members and associates as part of assessment
8. Evaluate and identify deterioration in mental health from one presentation to next
9. Consider use of Emergency Triage Liaison Service in appropriate cases in rural hospitals
10. Psychiatric evaluation be sought for patients making repeated presentations
11. Amend Mental Health Act 2009 to delete requirement for impaired decision-making capacity as prerequisite for Inpatient Treatment Orders and Community Treatment Orders except for electroconvulsive therapy and neurosurgery
12. SA Health implement electronic systems such as 'journey boards' to improve visibility of high-risk mental health patients and ensure appointments and follow-up are not missed
13. Improve communication systems between emergency departments, mental health services, community health teams and general practitioners
14. Access to clinical records across SA Health databases should be enabled for GPs working in rural settings
15. Enhance clinical supervision of psychiatrists in rural areas
16. Provide after-hours face-to-face mental health cover in country SA areas