Coroner's Finding: Roberts, Nigel Douglas

Contributing factors

• excessive sedating medication administration without adequate respiratory monitoring
• failure to recognise respiratory depression risk despite known COPD
• lack of continuous pulse oximetry monitoring
• inadequate respiratory rate monitoring and charting
• failure to exclude delirium as cause of agitation
• vague observation orders without specific parameters
• absence of specialist respiratory input
• cumulative effects of multiple psychotropic medications not assessed
• lack of communication and coordination between mental health services, aged care facility, and general practitioner
• absence of comprehensive management plan addressing both mental and physical health
• poor continuity of care due to reliance on locum clinicians

Coroner's recommendations

1. Tasmanian Health Service, in concert with relevant governmental authorities, should coordinate a strategy to establish a suitable facility on the North West Coast providing supported accommodation for persons suffering from mental illness unable to care for themselves
2. Systems should be developed to improve communication between Spencer Clinic and Department of Emergency Medicine
3. Systems should be developed to improve communication between Spencer Clinic and General Medicine, NWRH
4. Systems should be developed to improve communication between all mental health services and outside agencies including General Practitioners and Aged Care facilities
5. Nursing handovers in Spencer Clinic should be structured to include discussion regarding physical illness and observations
6. Process should be developed to ensure continuous training and up-skilling of clinical staff in basic life support, IV cannulation and other procedural skills
7. Formal mental health examination needs to be recorded for each mental health patient for each shift
8. Formal process should be developed with respect to registrar handover after hours and on weekends
9. System should be developed to improve case-specific and general discussion between nursing administration in Spencer Clinic and NWRH nursing specialist staff
10. NWRH should consult with Respiratory Department at Royal Hobart Hospital regarding adoption of oxygen prescription guideline for COPD
11. Processes should be developed to ensure direct admission patients are appropriately monitored with particular emphasis on patient safety and comprehensive evaluation within 24 hours of admission
12. State-wide system should be developed to ensure patients seen in Emergency Department have a complete medical assessment
13. Discussion should be instituted to align seclusion and restraint procedures initiated in Emergency Department with requirements of Mental Health Act 2013