Finding into death of Thien Cong Pham

Contributing factors

• co-patient with treatment-resistant schizophrenia and documented high risk of interpersonal violence not adequately separated from deceased
• patient bedroom doors not kept closed overnight despite policy requirement, enabling co-patient access
• inadequate assessment of co-patient's mental state deterioration prior to cessation of seclusion
• insufficient seclusion period despite difficult-to-assess presentation and chronic high violence risk
• non-enforcement of policy to keep bedroom doors closed at night
• limited intermediate-security facilities; only seclusion or open ward available
• inadequate staffing levels overnight (three nurses for 15 patients)
• unreliable observation records due to falsification by nursing staff
• risk assessment tools (DASA) failed to detect acute violence risk
• medication non-compliance detected but not escalated to treating psychiatrist
• lack of standardized policy on response to suspected medication non-compliance
• minimal seclusion courtyard trialling period before release to open ward
• difficult-to-read co-patient presentation limiting ability to assess risk escalation

Coroner's recommendations

1. Maintain enforcement of policy requiring patient bedroom doors to remain closed overnight
2. Establish high-dependency/intermediate-security unit for patients who cannot be safely managed in seclusion or open ward (Department of Health and Human Services to establish High Dependency Unit)
3. Implement and enforce standardized policies and protocols for nursing staff response to actual or suspected medication non-compliance
4. Review and enhance risk assessment protocols to better predict and manage imminent interpersonal violence risk, particularly for patients with chronically high risk that is difficult to anticipate
5. Establish or enhance multi-agency communication and planning processes (Forensicare, Corrections Victoria, Justice Health) to identify and manage transfers of extremely high-risk prisoners earlier (High-Risk Panel established operating from June 2013)
6. Review adequacy of overnight staffing levels in acute forensic units to enable more intensive observation and supervision of highest-risk patients
7. Ensure all nursing staff comply with observation policies and that observation records accurately reflect actual observations conducted; implement audit mechanisms
8. Standardize mental state examination protocols and documentation to improve consistency and quality of risk assessment
9. Consider development of intermediate care zones or de-escalation areas for management of patients between seclusion and open ward (de-escalation areas subsequently introduced)
10. Continue and evaluate High-Risk Panel effectiveness in identifying and planning management of extremely high-risk patients