Finding into death of Richard Hilton

Contributing factors

• Inadequate mental health assessment and follow-up despite multiple ED presentations
• Failure to arrange consultant psychiatrist review despite three presentations in two months
• Lack of coordinated care plan between public mental health services and private practitioners
• Staff focused on benzodiazepine withdrawal rather than underlying psychiatric illness
• Absence of documented shared care arrangements
• Assumed level of engagement with services that was not present
• Inadequate recognition of dual diagnosis (mental illness and substance dependence)
• No mental health outpatient follow-up arranged after final ED assessment

Coroner's recommendations

1. Werribee Mercy Mental Health (WMMH) should endorse and incorporate its draft procedure titled ECATT Assessment Review into practice, which requires that clients presenting three or more times within a fortnight for ECATT assessments with ongoing identified risk factors and/or diagnostic uncertainty must be referred to CATT for Medical Officer review and diagnostic clarification, and that all psychiatric assessments by ECATT clinicians in the ED are reviewed the following day by a senior clinician