Finding into death of Moufid Sawan

Contributing factors

• Failure to access comprehensive psychiatric history including arson and suicide attempts
• Breakdown in communication of critical information about patient asking for petrol
• Inadequate escalation of safety concerns by junior nursing staff
• Leave not reviewed when critical risk information emerged
• Risk assessments based on direct questioning alone without consideration of historical risk patterns
• Lack of formal protocols for escalating critical information from ward staff
• Medical records not effectively transferred from referring team

Coroner's recommendations

1. Mental Health Program to develop process ensuring previously documented clinical information is readily accessible to all clinical staff
2. Staff to utilize Scanned Medical Record (SMR) to obtain relevant past history and provide current clinical information; in-service education sessions were to be provided
3. Team Managers to ensure 100% of staff registered understanding of SMR user guide
4. Orientation to electronic medical record system to be included in organizational and local induction procedures
5. Review Clinical Risk Management training to include and highlight need to incorporate all clinical and other relevant sources of information in risk assessment
6. CRM training to be made compulsory for all Mental Health Program staff as part of core competency training
7. Review Mental Health Act leave of absence procedure to ensure leave is reviewed in conjunction with changes in patient's most recent risk assessment and nursing care level
8. Introduce leave form for voluntary patients
9. Conduct audit of leave procedure compliance
10. Establish clear documented escalation procedures for mental health nursing staff using ISBAR principles for shift-to-shift handover