Finding into death of Samer Rony Damouni

Contributing factors

• Suboptimal security provisions at hospital
• Absence of dedicated security staff in ED despite high absconding risk
• Inadequate assessment area for mental health patients in ED
• Lack of acute psychiatric inpatient beds leading to prolonged ED stay
• Failure to adequately assess and manage absconding risk
• Lack of coordinated assessment between mental health and emergency teams
• Inadequate consideration of chemical or physical restraint
• Constant Patient Observer without dedicated security presence
• Mother's warning about potential absconding and mention of death not fully integrated into assessment

Coroner's recommendations

1. Implement a Behavioural Assessment Room at Casey Hospital and, if appropriate, across Monash Health network
2. In conjunction with Better Care Victoria, implement a Behavioural Health Precinct at Casey Hospital and, if appropriate, across Monash Health network
3. In conjunction with Better Care Victoria, increase acute mental health inpatient bed capacity at Casey Hospital and, if appropriate, across Monash Health network
4. Review manner in which clinical histories are obtained by staff when performing mental health assessments for patients presenting at ED
5. Review policies or procedures for incorporating information received from third parties about patients presenting to ED, particularly those with psychiatric conditions