Finding into death of Paul Gary Larman

Contributing factors

• Inadequate safety assessment before dispensing one month's supply of clozapine to patient at high suicide risk
• Failure to recognise high-risk period following transfer between mental health services
• ED doctor prescribed clozapine without contacting patient's mental health service despite awareness of psychiatric history
• No communication between ED and mental health services
• Insufficient follow-up frequency in initial weeks after care transfer
• Patient's ability to stockpile clozapine through dose reduction and non-compliance habits
• Patient presenting sedated and under substance influence at initial assessment
• No risk assessment of self-administration capability at time of transfer
• Appointment scheduling based on clozapine protocol rather than individual patient needs

Coroner's recommendations

1. SHMHS and PHMHS review existing policies and procedures related to clozapine to address management of patients' own medication supplies at point of transfer and change from one brand of clozapine to another
2. Peninsula Health include information on restrictions of clozapine prescribing in training and orientation of all medical officers to decrease risk of inappropriate and unsafe patient access to clozapine
3. PHMHS review guidelines to increase frequency of review of clozapine patients in initial weeks following transfer from another mental health service, recognizing this as a high-risk period