Finding into death of Simon Rhys MacQueen

Contributing factors

• communication breakdown between Ward of Moreland Health and MCCT
• failure to communicate discharge summary to general practitioner
• lack of telephone call between treating psychiatrist and GP despite co-shared care
• absence of crisis/emergency plan at first outpatient consultation
• inadequate documentation of clinical notes and decisions
• discharge precipitated by patient refusal to return to unit rather than clinical decision
• lack of family engagement in care planning despite known protective relationship
• disengagement from services and non-adherence to follow-up

Coroner's recommendations

1. At every first contact with MCCT there must be a telephone call with the general practitioner or service with whom care is shared
2. Clinicians must be provided an opportunity to make important notes prior to commencing subsequent consultation
3. Discharge summaries must contain all relevant information in respect to treatment and medication plans, provision of medication to the patient and circumstances of discharge and confirmation with co-sharing professionals in the community are contacted by telephone and with follow up discharge plan
4. MCCT creates a Crisis/Emergency plan at the first consultation, ideally to encompass a crisis pathway for families