Finding into death of Peter Robin Tully

Contributing factors

• Inadequate engagement with collateral information from family and carers
• Failure to recognize patient's deliberate misrepresentation of mental state to clinical team
• Incomplete discharge planning
• Lack of designated case manager for first admission
• Delayed first post-discharge GP appointment (5 days)
• Psychologist referral not actioned (3-week wait)
• Accommodation arrangements not confirmed with key carers before discharge
• Carers not informed of discharge plan or their supportive role
• Failure to ensure completion of planned overnight leave before discharge
• Absence of early intensive post-discharge follow-up
• Patient's anxiety about discharge and concerns about managing in community not addressed

Coroner's recommendations

1. Clinicians remain attentive to the contribution made by the patient's family and carers and incorporate into their decision making process their knowledge of his or her behaviour and thinking
2. The Chief Psychiatrist facilitate development of a tailored information package to all patients, their family members and carers on first admission to an approved mental health service
3. The Chief Psychiatrist inform herself about the preferences of clients, families and carers before she determines how best to communicate with them about what they can expect to experience during and after their first admission to an approved mental health service
4. The Chief Psychiatrist publish clinical practice guidelines to assist approved mental health services concerning practice in relation to case management and discharge planning for all first admissions to acute adult mental health services
5. The Austin Hospital adult psychiatry unit ensure that discharge plans for first admission patients always include appropriate short to medium term accommodation arrangements and that cohabitants agree to these arrangements before discharge
6. The Austin Hospital adult psychiatry unit ensure that discharge plans for first admissions always include immediate transfer back to and communication with their known general practitioner
7. The Austin Hospital amend its new discharge arrangements to include daily contact by NECATT until patients have consulted their general practitioner and their management has been transferred back to them
8. The Chief Psychiatrist amend clinical practice guidelines to advise that the same or similar practices apply to discharge of voluntary patients as already apply to involuntary patients
9. In the alternative, the Austin Hospital acute adult psychiatry unit appoint case managers for voluntary first admission patients to help them manage their discharge arrangements and follow them into the immediate post discharge phase of their therapy
10. The designated case managers take responsibility for ensuring that the clinical team maintains contact with first admissions in the early post discharge period until patients have consulted their general practitioner and their management has been transferred back to them and coordinate post discharge supports