Coroner's Finding: Furlan, Mark John & Miller, Richard John

Contributing factors

• Failure to diagnose psychotic depression in Mark Furlan
• Inadequate communication of psychiatric assessment findings to treating team
• Inappropriate observation level (close rather than continuous observations) for patients at imminent risk of suicide
• Impracticality of maintaining close observations due to ward design and layout
• Missed observations due to workload and poor staffing allocation
• Inadequate exploration of suicidal statements in Richard Miller
• Poor documentation of suicidal intent context
• Inadequate Aboriginal liaison officer access and family engagement for Richard Miller
• Lack of continuity of care in community for Richard Miller prior to final admission
• Inadequate handover procedures between prison and hospital settings
• Visual observation practices through windows insufficient to detect ligatures
• Ineffective duress alarm and two-way radio systems
• Ward design features creating supervision challenges with no vision panels in acute rooms

Coroner's recommendations

1. Doors in Ward 2G acute patient rooms should be replaced as a matter of urgency with anti-ligature doors with viewing windows
2. CALHN should introduce electronic observation records for all mental health wards that can be transported with nurses, recording exact times and providing alerts for missed observations
3. All LHNs in South Australia introduce electronic observation records with alerts for observations due
4. CALHN should assess two-way radio coverage for black spots and resolve if practicable
5. Minister for Health and CALHN should review policies on admission of patients to mental health wards on Friday evenings or weekends to ensure adequate psychiatric input during high suicide risk period
6. CALHN should develop improved access to Aboriginal Liaison Officers and Aboriginal Mental Health Workers with sufficient resourcing
7. Mental health visual observation policies should be amended to require direct viewing of patients at night, not through windows
8. CALHN should implement Dr D.'s recommendations including: review of risk assessment and management policies; clear procedures for DCS patient visiting rules; review of prisoners' procedures in PICU; smooth handover procedures from Adelaide Remand Centre; specialist forensic mental health beds; open disclosure procedures following incidents; trauma-informed ED management; and coordinated care for patients with complex chronic needs
9. SA Health should develop standard operating procedures for how families are to be notified of unexpected deaths
10. LHNs should develop consistent coordinated, assertive, interagency continuous care approaches complying with Office of Chief Psychiatrist standards for patients with complex needs