Finding into death of Paul Allan Skinner

Contributing factors

• informal practice of performing only hourly observations overnight instead of prescribed 15-minute observations
• falsified nursing observation records documenting 15-minute observations that were not actually performed
• failure of medical staff to detect the discrepancy between prescribed and actual observations
• poor communication between medical and nursing staff regarding observation requirements
• known ligature point in patient room not removed
• absence of occupational therapy services
• no medium dependency unit option between low and high dependency units
• failure to convey concerns about cord found with patient to treating psychiatrist

Coroner's recommendations

1. Every authorised psychiatric inpatient facility should endeavour to employ an occupational therapist
2. Consideration be given to creation of Medium Dependency Unit (MDU) at authorised psychiatric inpatient facilities
3. Produce guidelines to assist health services to design inpatient units that maximise adequate patient observations and to mitigate risk associated with ligature points
4. Implement clear and consistent process and documentation for nursing observations, with any change in observation level made after suitable discussion and documentation; frequency of observations over night shift should be congruent with daytime observations unless otherwise decided and documented
5. Incorporate supervision and accountability in observation processes to ensure no doubt as to nurses' responsibility to conduct observations as clinically indicated
6. Develop Risk Assessment and Risk Management Guidelines specific to inpatient/bed-based Adult Acute Units reflecting evidence-base and range of vulnerabilities
7. Implement three-yearly panel convened by Chief Psychiatrist to inquire into inpatient deaths and consider overall practice improvements