Finding into death of XY

Contributing factors

• Suboptimal psychiatric risk assessment on ED presentation that failed to account for prior suicide attempts or relapse prevention plan
• Discharge from ED despite stated refusal to engage with CAT clinicians without anticipating continued non-engagement
• Failure to establish involuntary admission despite ongoing suicidal ideation and overdose
• Failure to develop agreed discharge plan with patient
• No communication between EPS/NECAT and patient's ongoing care manager or continuing care service
• Failure to escalate to psychiatrist review during 3-day monitoring period
• Failure to change management plan in response to risk indicators (refusal to eat, refusal of medication, self-isolation, refusal of assessment)
• Inappropriate delegation of risk assessment responsibility to non-clinical SRS staff without clear safety planning or escalation criteria
• Unclear whether multidisciplinary clinical review occurred on 11 January 2016

Coroner's recommendations

1. Department of Health and Human Services, in conjunction with Supported Residential Services, Mental Health Services, Mental Health Community Support Services and Consumer Representation, should develop a guide improving safety of SRS residents with acute deterioration in mental state. The guide should: (a) ensure SRS staff receive current safety plans during periods of deterioration; (b) engage residents in safety plan development where possible; (c) enable safety planning even when resident refuses to engage, pending later engagement; (d) specify elements of safety plans including clear contact details and circumstances requiring escalation; (e) define expected responses from engaged mental health services; (f) reflect realistic SRS staffing levels and skill limitations; (g) require notification when acute risks resolve and safety plan is no longer current.