Finding into death of Benjamin Jason Pappas

Contributing factors

• inadequate crisis management plan
• unavailability of treating GP at critical time
• substance abuse (heroin, benzodiazepines, amphetamines)
• depression and suicidal ideation
• borderline personality disorder
• acute psychotic symptoms related to drug use
• discovery of partner's death and police investigation pressure
• lack of written crisis plan with telephone numbers and appointment schedule

Coroner's recommendations

1. Health care professionals treating patients with substance abuse and mental health issues should ensure they have comprehensive crisis management plans that include: written plans signed by patients; specific appointment times; contact numbers for specialists; and alternative on-call support arrangements
2. GPs should be aware of and implement clinical guidelines for managing couples where family violence is present or suspected
3. Health professionals should ensure they have adequate on-call assistance and backup to support and guide them when treating complex patients with potential risk to themselves or others
4. A false sense of being able to control situations through direct personal contact should not be relied upon; appropriate safeguards and alternative contact pathways are essential
5. When health professionals are aware of potential risk to another person (as intimate partners), the safety of the person at risk must come first