Finding into death of Narelle Ena Clancy

Contributing factors

• Absconding from unlocked low-dependency psychiatric ward
• Open door policy in LDU with inadequate staffing during meal breaks
• Insufficient documentation of risk assessments and clinical management plans
• Lack of documented communication of 'low threshold' transfer criteria to ICA
• Inadequate supervision and engagement with patient during afternoon of absconding
• Change in patient behaviour not leading to escalation or transfer to higher-acuity unit
• History of suicidal ideation and previous suicide attempt
• Complex mental health history without clear diagnosis

Coroner's recommendations

1. Implementation of formalised Clinical Risk Assessment and Management (CRAAM) guidelines with documented safety plans completed by treating teams and reviewed at regular intervals
2. Documentation of risk assessments and communication of clinical management plans must be clearly recorded in medical records
3. Transition from mechanical 15-minute sight observations to more meaningful, frequent patient engagements by contact nurses with assessed level of risk determining frequency
4. Implementation of locked LDU doors at all times, with patients requiring staff to open doors if they wish to leave
5. Enhanced supervision protocols during staff meal breaks to reduce absconding risk
6. Regular training of nursing and medical staff on risk assessment, documentation and communication of management plans