Finding into death of ARCHIVE Finding Hunter Joseph Stewart

Contributing factors

• Commencement of methadone without prescriber knowledge of concurrent benzodiazepine use
• Patient non-disclosure to general practitioner of current psychiatric medications and recent hospital admission
• Failure of community mental health referral - declined by receiving service without documented communication to discharging team
• Gap in discharge transfer of care processes between services
• Continued illicit substance use (heroin, amphetamines) while on methadone and benzodiazepines
• Underlying depression and addiction with poor medication compliance post-discharge
• Lack of clinical oversight of intake decisions at community mental health service
• Absence of proactive follow-up to ensure discharged patient made contact with referred services

Coroner's recommendations

1. Implementation of real-time prescription monitoring systems to enable prescribers to identify patients' concurrent medications, particularly the combination of benzodiazepines and opioids
2. Enhanced discharge transfer of care protocols to require documented acceptance of referrals and escalation procedures for refused transfers
3. Establishment of proactive follow-up systems for discharged psychiatric patients to ensure contact with referred services
4. Clinical oversight of intake decisions at community mental health services, particularly for declined referrals
5. Recording of all intake interactions electronically with periodic consultant psychiatrist review
6. Development of transition coordinator roles to bridge gaps between acute and community mental health services