Finding into death of Lynette Roberts

Contributing factors

• Absence of formal leave policy for CCU patients
• Delayed initiation of search—5+ hours after departure despite known pattern of dishonest reporting of destination
• Failure to notify family of transfer from secure to community unit
• Inadequate monitoring of patient movements despite elevated risk indicators on 14-15 December
• Lack of contemporaneous risk assessment documentation
• Cognitive dysfunction and negative symptoms of schizophrenia despite partial treatment response
• Patient alcohol consumption while on leave
• Inappropriate staff responses to family concerns about patient vulnerability
• Co-location of SECU and CCU with shared staffing reducing dedicated supervision of CCU
• Lack of specific guidance or policy on management of missing CCU patients

Coroner's recommendations

1. Produce a clear written leave policy for CCU patients detailing expectations for staff and patients when patients leave grounds, with verbal explanation to patients at admission and notification to relatives
2. Inform next of kin at minimum 24 hours before SECU to CCU transfer to allow input into decision
3. Provide regular and refresher training to staff on conducting risk assessments to ensure uniformity
4. Require nursing staff to make comprehensive contemporaneous patient notes prior to conclusion of their shift
5. Provide training for all staff (not limited to psychiatrists) on Chief Psychiatrist's guidelines particularly regarding communication and engagement with relatives and carers