VIChospital

Finding into death of TM Y

Deceased

TMY

Demographics

52y, male

Coroner

Coroner Rosemary Carlin

Date of death

2011-01-23

Finding date

2014-07-10

Cause of death

Hanging

AI-generated summary

A 52-year-old man with long-standing mood disorders, depression and suicidal ideation was apprehended under Mental Health Act section 10 after acute suicidal behaviour including self-harm. He was brought to Casey Hospital ED with active police escort at 9:55 PM on 22 January 2011. Despite explicit police warnings about his stated intention to obtain release and then kill himself, he was erroneously discharged at 12:48 AM without undergoing formal mental health assessment. A miscommunication occurred between the ECATT nurse (who believed a full assessment should await sobriety) and the ED junior doctor (who mistakenly believed the nurse had assessed him as low-risk). The patient was released back into the community with no money or means of transport. He died by hanging the following afternoon. While causation was not established, the coroner found systemic failures in hospital procedures for managing section 10 patients, inadequate role clarity between medical and mental health staff, and lack of documentation requirements that could have prevented the erroneous discharge.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

emergency medicinepsychiatry

Error types

communicationsystemprocedural

Drugs involved

alcohol

Clinical conditions

depressionsuicidal ideationacute suicidal behaviourmood disorderalcohol intoxication

Contributing factors

Erroneous discharge from ED prior to mental health assessment
Miscommunication between ECATT nurse and ED doctor regarding patient assessment status
Absence of documented procedures for section 10 patient discharge
Lack of clarity regarding roles and responsibilities of ED doctor versus ECATT clinician
Failure to recognise intoxication does not preclude suicide risk assessment
Inadequate record-keeping by nursing staff
Patient released without means of transport or contact with family
Release during night-time adjacent to railway line
Patient's known intent to manipulate clinicians to achieve release

Coroner's recommendations

Monash Health introduce a clear written procedure whereby patients brought into an Emergency Department by police pursuant to Section 351 Mental Health Act 2014 cannot be discharged prior to a mental health assessment and completion of a Mental Health Assessment Form.
Monash Health introduce a clear written procedure in the event a patient brought into an Emergency Department by police pursuant to Section 351 Mental Health Act 2014 absconds or is discharged without a mental health assessment. Particular consideration should be given to requiring immediate notification of Emergency Services Telecommunications Authority (ESTA) and the on-call consultant psychiatrist.
The Chief Commissioner of Police, Monash Health and the Department of Health investigate the feasibility of requiring the Mental Disorder Transfer Form to record the signature of the person to whom custody has been transferred, as well as the date and time of transfer.

Full text

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Source and disclaimer

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