Finding into death of David Allan D'Angelo

Contributing factors

• Absconding from Low Dependency Unit
• Heroin use following discharge from supervised care
• Three-hour delay in reporting missing person to police
• Inadequate absconder policy lacking clear reporting timelines
• Patient access to personal belongings (bank cards, phone) facilitating movement and ability to obtain drugs

Coroner's recommendations

1. The Missing and Absconded Patients policy should be reviewed to include specific timelines for police notification; involuntary absconding patients should be reported to Victoria Police within 30 minutes if high-risk or within 1 hour if lower risk after unsuccessful immediate search
2. Photographs of patients taken during current episodes of psychiatric care should be provided with missing person reports to Victoria Police, with appropriate safeguards around access, retention and use
3. Alfred Health should improve documentation of personal items returned to involuntary inpatients and the clinical rationale for such returns
4. Alfred Health should review policies around access to personal belongings for involuntary patients, with consideration of the balance between least restrictive care and patient safety
5. Key agencies including Ambulance Victoria, Victoria Police and psychiatric facilities should improve inter-agency information sharing and data systems to identify and locate absconded involuntary psychiatric patients, particularly those who have had emergency services contact