Finding into death of Angelo Lombardo

Contributing factors

• Over-sedation with high-dose clonazepam and olanzapine in ambulance bay without titration to effect
• Inadequate security arrangements forcing ED staff to adopt high sedation as compensatory measure
• Delay in psychiatric registrar assessment and bed availability
• Absence of rapid sedation guidelines at time of admission
• Lack of ECG or cardiac investigations despite multiple risk factors and antipsychotic use
• Extended length of stay in ED (14 hours) delaying appropriate psychiatric inpatient care

Coroner's recommendations

1. Werribee Mercy Hospital review all aspects of its security arrangements including provision of adequate numbers of security personnel and seclusion rooms commensurate to better practice standards
2. Werribee Mercy Mental Health review its current Guidelines for Management of Acute Behavioural Disturbance to ensure consistency with other Victorian mental health facilities
3. Support adoption of a statewide approach to Rapid Sedation Guidelines not dissimilar to those for management of acute behavioural disturbance
4. Implement clear protocols for timely psychiatric assessment and admission processes to reduce ED length of stay for psychiatric patients