Finding into death of Gerard Helliar

Contributing factors

• Continuation of ECT without reasonable basis for success
• Insufficient consideration of ECT side effects and patient opposition
• Inadequate risk assessment on day of death
• Failure to escalate concerns about incomplete mental state assessment
• Downgrading of suicide risk despite recent bilateral ECT and inability to engage patient
• Insufficient environmental safeguards including access to belt and ligature points
• Treatment-resistant bipolar affective disorder with chronic suicidal ideation
• Lack of alternative treatment explored despite 200+ previous ECT treatments

Coroner's recommendations

1. The Office of the Chief Psychiatrist should review all relevant research and advise the mental health profession on how patients with bipolar affective disorder who are acutely depressed and resistant to ECT over a prolonged period (and who have objected to its use) should be assessed and managed in hospital settings, with consideration of alternative management methods in accordance with the Mental Health Act 2014 and the Victorian Charter on Human Rights and Responsibilities Act 2006
2. The Office of the Chief Psychiatrist should amend the December 2015 ECT guidelines to provide greater direction regarding the type, frequency, and appropriate manner of calculation of the top end limit of shock delivery for all ECT administration, and should include direction regarding anaesthesia delivery in connection with the condition under treatment
3. The Office of the Chief Psychiatrist should review its approach to permitting personal items of potentially dangerous nature (such as belts and cords) into psychiatric hospital units
4. Peninsula Health should create a new audit team responsible for assessing ligature point risks in Ward 2b at Frankston Hospital, answerable directly to the Chief Executive Officer and chaired by an independent person with appropriate training and experience in hospital risk assessment