Finding into death of Dean Alan Carlson Laycock

Contributing factors

• Abrupt reduction of anticipated Christmas leave without adequate consultation
• Failure to consult patient and mother in clinical team decision-making
• Inadequate clinical handover from ABC to PARC
• Consultant psychiatrist (Dr E.) had never met the patient prior to decision
• Consultant psychiatrist did not review patient's clinical file prior to decision
• Consultant psychiatrist did not speak with prior treating psychiatrist (Dr M.)
• Decision made on hearsay about mother's capacity to cope—never verified with her
• Poor timing: decision communicated moments before departure, no time to process
• Lack of documented notes from clinical team meeting
• No treatment plan attached to Community Treatment Order as required
• Patient's intellectual disability not adequately considered in communication approach
• No mortality review conducted after patient's death

Coroner's recommendations

1. Mandated minimum requirements of documentation must transfer with patients from inpatient facilities to PARC, including at minimum patient records from the previous 7 days. Minimal reliance on verbal handover.
2. BHCG should prepare its own policy on granting leave from PARC, reflecting the Chief Psychiatrist's guidelines on inpatient leave. Policy should emphasise decisions made with full understanding of patient's background and circumstances, with consultation and involvement of patient and carer, and fully informed explanation of reasoning.
3. All existing BHCG policies must be properly explained to staff with regular, mandatory training on policies and their implementation. Consider fixed programs for ongoing staff education including internal policies and Chief Psychiatrist's guidelines.
4. Clear chain of responsibility established for overseeing internal review of patient deaths.
5. Clinical team meetings should not discuss a patient unless the consultant psychiatrist has actually met with the patient and reviewed their file, which should be more achievable given increased psychiatrist attendance.