Finding into death of Palma Castro

Contributing factors

• failure to update formal risk assessment tool upon re-admission
• inadequate documentation of planned follow-up arrangements with Crisis Assessment and Treatment Team (CATT)
• failure to obtain medical review following re-admission within 5 hours of discharge
• insufficient communication with family regarding their understanding and capability to perform required supportive role
• dismissal of family's expressed concerns and reluctance to accept discharge plan responsibility
• lack of clarity regarding discharge plan details including who would contact whom and when
• failure to inquire about previous suicide attempt in 2009 at first presentation
• benzodiazepine withdrawal with rebound anxiety
• multiple psychosocial stressors including relationship breakdown and homelessness

Coroner's recommendations

1. Risk assessment tools must be updated upon each admission
2. Planned follow-up arrangements with CATT must be clearly detailed post-discharge
3. When a patient is discharged to family, clear explanation is required to ensure family members fully understand what is required of them and accept the responsibility to ensure the safety of the patient, with follow-up details clearly established including who they can contact if something goes wrong
4. Pressure must not be brought to bear on a family to accept responsibility of discharge of a patient if they express reluctance, discomfort and/or inability to perform a role in the discharge plan
5. If a medical review is not considered necessary upon re-admission of a patient the reasons for this decision must be clearly articulated on the hospital record
6. The Office of the Chief Psychiatrist disseminate these lessons across all Victorian mental health services
7. The Department of Health and The Office of Chief Psychiatrist consider the development of PECC (Psychiatric Emergency Care Centre) units to service patients in crisis in need of short-term admissions