Finding into death of RJA
Deceased
RJA
Demographics
30y, male
Date of death
2011-04-26
Finding date
2013-04-10
Cause of death
Multiple injuries from impact by train
AI-generated summary
A 30-year-old man with schizophrenia was admitted to Frankston Hospital in March 2011 after presenting to the Emergency Department. He was discharged after approximately 2.5 weeks to community mental health services. Key clinical documentation deficiencies were identified: the diagnosis of schizophrenia was not clearly recorded in medical notes despite being discussed, the family was not adequately informed of the discharge plan despite being listed as next of kin, and there was poor adherence to the service's Family Sensitive Practice guideline. While the patient's risk assessment prior to discharge appropriately rated him as low risk and detention would have been inappropriate for a voluntary patient, the failure to properly involve and inform parents in discharge planning represented a significant breach of clinical practice guidelines. The patient died by suicide approximately three weeks after discharge.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- Schizophrenia
- Poor documentation of diagnosis in medical records
- Inadequate family involvement in discharge planning
- Parents not informed of discharge plan despite being listed as next of kin
- Failure to adhere to Family Sensitive Practice guidelines
- Delay in notifying parents of initial admission
- Out of date contact details on medical records
- Unclear documentation regarding patient attendance at family conference
- History of self-harm attempts
Coroner's recommendations
- That Peninsula Health should ensure all medical, nursing and allied health personnel are adequately trained in, informed of and adhere to the PHMHS Clinical Practice Guidelines.
- That patient's notes are the official record of patient care and medico-legal record. Formal consideration should be given to include in the guidelines the types of information that should be documented including reasons for decisions to be set out on the patient's file.
Full text
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