Coroner's Finding: Kirkwood, Jordan Thomas

Contributing factors

• depression
• cannabis withdrawal
• acute relationship breakdown
• suicidal ideation
• admission to insufficiently established community mental health program without adequate safety protocols
• failure to recognize imminent risk of self-harm after multiple suicide attempts
• lack of key worker and rapport building
• inadequate assessment of medication overdose
• poor emergency department awareness of MHHITH program
• non-functional after-hours telephone line for MHHITH
• inadequate focused psychological treatment
• lack of involvement of significant others in care planning

Coroner's recommendations

1. Implement in full the RCA recommendations: (1) Complete and endorse MHHITH documentation within 3 months and make widely available; (2) Ensure entry into record reflects what service is being provided rather than individual consultant's name; (3) Provide comprehensive education sessions on Digital Medical Record documentation processes; (4) Revise MHHITH admission criteria to provide greater guidance on admission suitability for clients who have made recent self-harm and/or suicide attempts; (5) Consider access and availability for psychological intervention where clinically indicated; (6) Ensure involvement of significant others in provision of collateral information where consent provided
2. Limit the number of medical and allied staff involved in mental health patients' care to as few as possible to avoid difficulties with trust and rapport building, and avoid constant staff changeover
3. Finalize responses to Coroner McTaggart's 2015 recommendations regarding dedicated inpatient unit for adolescents and young adults aged 12-25 years, suicide prevention coordinators, and state-wide suicide risk assessment tools as soon as reasonably possible
4. Ensure ED staff awareness of MHHITH program and that after-hours telephone service is tested and operational from program commencement
5. Establish seamless integration between MHHITH and ED so that deteriorating patients can be moved to inpatient care without delays
6. Implement procedures to ensure MHHITH team reviews clinical decisions when patients present with repeated self-harm incidents or fail to meet eligibility criteria
7. Develop protocols requiring clinicians to consider behavioural evidence alongside patient verbal reports, particularly when patient actions contradict stated intentions
8. Establish retainer arrangements with private sector psychologists to ensure timely access to psychological treatment for community-based mental health patients