Finding into death of Travis Andrew McNees

Contributing factors

• relationship breakdown
• recent suicide attempt (paracetamol/panadeine overdose)
• history of self-harm behaviour
• depression with suicidal ideation
• absconding from ward
• inadequate communication between CATT and psychiatric team
• reduced level of observation on discharge day
• unescorted leave permitted on final day
• psychiatrist did not perform scheduled review on day of death

Coroner's recommendations

1. CATT clinician should conduct face-to-face meetings rather than telephone reviews
2. Verbal communication between CATT and ward staff must be entered in clinical file
3. Psychiatrist should read all referral notes and be informed of revised risk assessments
4. Consultant psychiatrist should precisely set out proposed duration of escorted leave periods
5. Close observations should be maintained for first 2-3 days of admission
6. Medical input required for all decisions to reduce visual observations
7. Patients should not be permitted unescorted leave during high-risk periods
8. Nursing observations documentation must be accurate
9. Intended duration of leave periods should be prescribed by Consultant Psychiatrist
10. Visitors should meet nursing staff on arrival and departure
11. Patients and visitors should meet contact nurse prior to leaving ward and upon return
12. Patients should be assessed before and after periods of escorted leave
13. Visitor book should be maintained with visitor names
14. Reception should display sign requesting visitors to contact nursing staff
15. Head count should be conducted at 8.00pm when ward is locked
16. 9.00pm handover process should include patient contact confirmation
17. Eastern Health should consider creation of intermediate option between LDU and HDU
18. LDU patients should not be locked in during daylight hours unless acuity requires containment
19. Open door policy should be maintained in LDU in accordance with Mental Health Act spirit and intent