Finding into death of Mark Bethell

Contributing factors

• failure to implement involuntary admission despite clear indicators
• inappropriate discharge without risk assessment or medications
• mischaracterisation of abscondence as 'leaving against medical advice'
• superficial and dismissive risk assessment on 20 March 2008
• failure to escalate care despite urgent warning from caseworker
• lack of medication supervision in community setting
• failure to follow Continuum of Care Protocol after abscondences
• failure to implement treating psychiatrist's management plan
• inadequate communication between hospital and community services
• lack of access to prescribed psychiatric medications
• unresolved stressors regarding accommodation and employment

Coroner's recommendations

1. The Department of Health should investigate how best to facilitate arrangements for inter-hospital transfer of voluntary and involuntary patients, reasonably involving discussion between units at Consultant level
2. Ongoing training of CATT clinicians should further emphasize the need for risk assessments in suspected Borderline Personality Disorder cases, particularly addressing safety around patient's potential for ongoing self-administration of prescribed medication
3. Where CATT clinicians know that patients with Borderline Personality Disorder are returning to community facilities, relevant information and advice should be passed to facility managers to allow collection of medication supplies and centralized distribution
4. Oznam House should introduce a prescription medication management programme for resident clients where admission or subsequent risk analysis establishes an occupational health and safety need