Finding into death of K

Contributing factors

• suicide by self-directed vehicle collision
• inadequate CAT Team assessment documentation
• delayed CAT Team response (8 hours from initial call)
• failure to adequately engage family despite clear parental concerns
• misdiagnosis of psychiatric symptoms as purely drug withdrawal
• dual diagnosis complexity not adequately addressed
• inadequate risk assessment for patient with fluctuating mental state
• no systemic triage rating scale in place
• limited pathway for dual diagnosis admissions
• no after-hours access to drug and alcohol services

Coroner's recommendations

1. Implement centralised triage service with computerised screening register and triage rating scale (completed - 2-hour response target)
2. Mandatory comprehensive assessment documentation forms including 'home visit risk assessment form' and 'dual diagnosis substance use history form'
3. All patients deemed to not require CAT service to be reviewed by consultant psychiatrist within 24 hours
4. 20 hours mandatory annual training for CAT clinicians including clinical documentation and risk management
5. Comprehensive review of risk assessment processes service-wide
6. Regular audits of clinical documentation and risk management forms with staff performance appraisal review
7. Enhanced education on clinical documentation and medical-legal requirements
8. Restructuring rosters to ensure adequate staffing seven days a week
9. Development of improved pathways for dual diagnosis patients including direct admission to psychiatric facilities for those with suicide ideation withdrawing from drugs
10. Integration of drug and alcohol services with mental health services