Finding into death of Warren Guneratne

Contributing factors

• paranoid schizophrenia with labile mood
• recent relapse with suicidal ideation and plan
• recent illicit drug use (methamphetamine, cannabis)
• non-compliance with antipsychotic medication
• admission to low dependency unit despite high suicide risk
• systemic communication failure regarding risk assessment
• delay in psychiatric medical assessment (6 hours post-admission with none completed)
• delay in notifying police of absconding (1 hour 15 minutes)
• unlocked ward with unsecured exit points
• inadequate handover of critical risk information to morning shift staff

Coroner's recommendations

1. Review and develop clinical guidelines on risk assessment with particular reference to: significance of unknown patients; effect of recent drug use on mental health state; development of clinical prompts to escalate treatment plan
2. Include clinical collateral documentation as part of admission notes, particularly for consumers from areas outside service catchment
3. Review points of entry and egress within the ward and develop policy outlining when rear exit is accessible
4. Review training on dual diagnosis issues and ensure staff trained in assessment of impact of drug and alcohol use on mental state and risk assessment
5. Review policy on absence of inpatients to ensure risk assessment undertaken immediately when patient noted missing, consultant psychiatrist notified, and action plan instituted; all absent involuntary patients reported to police; medium to high risk patients reported to police regardless of legal status
6. Heighten courtyard fence and secure gate to prevent absconding