Coroner's Finding: Peck, Edward Paisley

Contributing factors

• inadequate consultation with treating psychiatrist before capacity assessment
• failure to obtain collateral information from family members despite availability
• lack of direct communication with treating psychiatrist Dr K. before finalising decision
• patient's presentation diverged from baseline behaviour yet this was not vigorously challenged
• understaffing and time pressure within Consultation Liaison Service may have contributed to less comprehensive approach
• Mental Health Act 2013 capacity test did not account for acute suicidality and self-harm in context of high baseline risk
• patient's drug dependence potentially driving impulsive decision-making not fully explored

Coroner's recommendations

1. Tasmanian Department of Health should undertake a review of the medical, nursing and administrative staffing requirements for the Consultation Liaison Psychiatry Service at Royal Hobart Hospital and provide further resourcing as required. The service was found to be drastically understaffed compared to international standards (British Royal College of Physicians and Royal College of Psychiatrists recommend 1-2 consultants, 1-2 registrars, 5 psychiatric nurses, administrative assistant and social worker/psychologist for a catchment area the size of Hobart; the actual team comprised 1 consultant and 1.5 registrars).
2. Closer liaison between public and private psychiatric services for high-risk clients, including involvement of primary care provider in coordinated management plan.
3. Clarification of the definition of capacity within the Mental Health Act 2013 to address fluctuating capacity which increases risk.
4. Education for staff regarding confidentiality and consent, particularly regarding strategies to obtain information from parents/carers while maintaining patient confidentiality.
5. Implementation of a single Information Technology system across Tasmania Health Service to ensure effective patient care across services.
6. Education for all doctors regarding the importance of interacting with parents/carers while respecting confidentiality to ensure corroborative history is gathered and parental concerns are validated.
7. Government to formulate and implement a plan for structural modifications to the Tasman Bridge to eliminate it as a method of suicide - including erection of appropriate physical barriers as a matter of urgency.
8. Installation of effective cameras, life line phones and signage on Tasman Bridge.
9. Establishment of a Suicide Register to inform suicide prevention strategies.