Finding into death of Stacey Jade Smith

Contributing factors

• Removal of mechanical restraints without adequate risk assessment
• Failure to implement continuous supervision as required by Mental Health Triage Tool
• Inadequate communication between emergency department and psychiatric team
• Delayed ECATT assessment with no communication about wait times
• Transfer from resuscitation cubicle to cubicle 13 without formal handover or supervision plan
• Emergency department overcrowding and understaffing
• Insufficient consideration of patient's immediate history of suicidal ideation
• No consultation with ECATT psychiatrist regarding security arrangements
• Absence of risk analysis before removal of one-to-one nursing care
• Delayed notification to police of patient's disappearance (1 hour delay)

Coroner's recommendations

1. Department of Health to review existing protocols concerning psychiatric review in hospital emergency departments
2. Establish arrangements to ensure that where delays in psychiatric review threaten to compromise patient care, there are provisions for consultant-level communication and options for either intra-hospital transfer to psychiatric unit or additional RPN attendance in ED
3. Ensure adequate staffing of ECATT services to prevent delays in psychiatric assessment
4. Strengthen implementation and compliance with Mental Health Triage Tool requirements for continuous supervision of category 2 psychiatric patients
5. Establish mandatory handover procedures when transferring psychiatric patients between cubicles
6. Require documented risk assessments before removal of restraints or supervised care for suicidal patients
7. Improve communication protocols between emergency department and psychiatric services