Finding into death of Daniel Colin McKittrick

Contributing factors

• Mental health assessment delayed at St Vincent's Hospital - patient left without being seen
• Lack of proactive follow-up contact with patient or family after unassessed departure from St Vincent's
• Inadequate weighting of recent suicidal ideation and railway yard incident in triage risk assessment at Royal Melbourne Hospital
• Voluntary patient status not recognized as insufficient safeguard against absconding when patient at imminent suicide risk
• Escort outside Emergency Department without appropriate environmental restrictions in place
• Lack of systematic communication between emergency departments about patients who leave without assessment
• No mental health diagnosis or formal assessment completed at Royal Melbourne prior to patient leaving

Coroner's recommendations

1. St Vincent's hospital should review or continue to review procedures and protocols to ensure that persons presenting on their own in relation to mental health issues are given every reasonable opportunity to ensure that someone they trust is contacted to be with them while waiting to be assessed, and if necessary, are assisted in making the contact.
2. The Department of Health should commission a review, in conjunction with relevant hospitals (St Vincent's and Royal Melbourne), of the systems of communication between service providers (Emergency Departments) to provide early communication and notification between Emergency Departments about patients who have attended seeking or requiring mental health treatment but who leave without being seen by a relevant medical practitioner. This should consider what aspects of the RAPID (or other) communication system could be improved by creating a notification system between Emergency Departments.