Finding into death of Finding Peter Graham Chaucer

Contributing factors

• Suicide by intentional act
• Diagnostic disagreement between private and public psychiatrists regarding bipolar disorder vs borderline personality disorder
• Lack of coordination between private psychiatrist and public mental health services
• Patient distrust of clinicians exacerbated by conflicting medical opinions
• Non-compliance with medications due to distrust and chaotic circumstances
• Reluctance of Emergency Department to admit despite patient requests and multiple presentations with suicidal ideation
• Inadequate recognition of deteriorating mental state and escalating risk
• Homelessness and unstable housing
• Police involvement and family violence intervention order
• Involvement of ex-wife as carer despite family violence issues creating conflict of interest

Coroner's recommendations

1. The Office of the Chief Psychiatrist and Royal Australian and New Zealand College of Psychiatrists should develop a shared protocol or guidelines for clinicians sharing responsibility for patient care across public and private sectors, addressing communication, transparency of arrangements with patients and carers, clinical responsibility in periods of crisis, and negotiated care planning.
2. Peninsula Health to establish and implement formal process to support shared care arrangements between mental health services and other private practitioners.
3. Peninsula Health to review and redevelop service-wide system to support recognition and identification of deteriorating clients (clinical, social and behavioural markers) with process of review and escalation.
4. Review current escalation processes across Clinical Risk Committee, Clinical Handover, Clinical Review, Case Conferencing, and Carer Led Escalation.
5. Review relevant Clinical Practice Guidelines to incorporate explicit guidelines relating to objective assessment and management of alcohol or other drug use including Blood Alcohol Concentration, Urine Drug Screening and Breathalyser testing.
6. Review process and criteria for development of Risk management plans including timeliness and interim plans.
7. Victorian Government to consider issue of carers who are also affected family members in intervention orders when responding to Royal Commission into Family Violence recommendations 97-100.