Coroner's Finding: Sowden, James Robert

Contributing factors

• Depression with anxiety
• Autoimmune thyroiditis
• Adverse medication reaction causing paranoia and panic attacks
• Lack of face-to-face psychiatric assessment before discharge
• Inadequate collateral history gathering
• No documented capacity assessment
• Absence of family risk management discussion at discharge
• Consultant psychiatrist decision made by phone without patient assessment
• Insufficient risk stratification despite lethal self-harm method

Coroner's recommendations

1. Risk assessments of acutely suicidal patients who have attempted suicide by lethal mode should include medical psychiatric assessment
2. Clinical staff should be reminded of the importance of collateral history gathering, particularly for first presenters with identified high risks
3. Mental decision-making capacity should be evaluated when key treatment decisions are made; mental status examination should focus on attention, mood, thinking, memory and cognitive function
4. Structured handover tool (ISOBAR) should be used to communicate with on-call consultants; on-call consultants should have access to digital medical records to clarify client history, presentation, risk and prior medical assessments before making treatment decisions
5. CATT MDT discussions must be fully documented with clear rationale for decisions to ensure consistent, easily interpreted plans available to all involved in care
6. All clinicians must ensure family are aware of risks and observation needs, gaining their agreement to risk management plan prior to discharge
7. Risk assessment skill training should be considered as mandatory training requirement for Statewide Mental Health Services