Finding into death of Melissa Jane Thorn

Contributing factors

• inadequate security/ward access controls - linen delivery door left propped open
• failure to identify and address risk posed by linen delivery process in secure ward
• patient's chronic suicidal ideation and history of suicide attempts
• patient's refusal of evening medications and stated intention to stay awake overnight
• confusion among staff about patient's legal status under Mental Health Act
• poor documentation and communication of clinical information
• patient in private facility not gazetted under Mental Health Act

Coroner's recommendations

1. Improve documentation of clinical information in medical records, including dated risk assessments, detailed past history, verbatim accounts of significant patient disclosures, and current clinical plans
2. Address verbal culture in hospitals where important clinical information communicated at handover is not documented in medical records
3. Remedy the lack of appreciation among nursing staff of Mental Health Act 1986 provisions governing recommendation for involuntary treatment and the need for timely transfer to gazetted psychiatric facilities
4. Identify and address risks posed by service delivery processes (such as linen delivery) in secure psychiatric wards, particularly regarding unsupervised access to exit doors
5. Review and improve security protocols for exits from secure psychiatric wards