Coroner's Finding: Lockwood, Shane

Contributing factors

• Inadequate implementation of Care Plan
• Excessive reliance on telephone contact rather than face-to-face meetings
• Case manager did not attend first depot injection
• Failure to closely monitor mental state following discharge
• Administrative bungling with medication supply at general practice
• Change in medication administration location from hospital to remote general practice
• Lack of personal support and coordination
• Practical difficulties accessing medications in rural location
• Patient distress about medication procurement process
• Insufficient liaison between psychiatric services and general practitioner

Coroner's recommendations

1. Ensure proper implementation of Care Plans for discharged psychiatric patients, particularly those under Community Treatment Orders
2. Require case managers to conduct regular face-to-face meetings rather than relying on telephone contact for close monitoring
3. Case managers should attend first medication administrations to ensure patients understand new arrangements and to assess the process
4. Ensure general practitioners caring for psychiatric patients are fully appraised of recent psychiatric history and their role in ongoing care
5. Develop strategies to address the challenges of managing psychiatric patients residing away from hospital in rural and remote areas
6. Support efforts to provide high levels of personal and coordinated support to persons with mental illness in the community