Finding into death of Risto Pedevski
Deceased
Risto Pedevski
Demographics
79y, male
Date of death
2014-11-23
Finding date
2017-07-12
Cause of death
Head and neck injuries from blunt force trauma
AI-generated summary
Mr Risto Pedevski, a 79-year-old man, was fatally assaulted by his son George in November 2014 during a dispute over a gas hot water system. George had a long-standing diagnosis of schizophreniform disorder and paranoid schizophrenia with persistent delusions and hallucinations. Critical clinical lessons include: failure by mental health services to adequately assess and manage risks posed to family members; inadequate risk assessments at discharge from Werribee Mercy Hospital in June 2013; poor information-sharing between mental health and aged care services; and failure to recognize family violence and elder abuse in hospital and community settings. Western Health staff prioritized their own safety over the discharged patient's safety. No family violence-specific safety planning or risk assessments were conducted. The case highlights the need for mandatory family violence training, specialist family violence advisors in mental health services, and binding guidelines for psychiatrists managing perpetrators of family violence.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- Inadequate risk assessment by mental health services regarding danger to family members
- Poor discharge planning and risk communication from Werribee Mercy Hospital
- Failure to recognize elder abuse and family violence by health service providers
- Lack of information sharing between mental health, aged care and community services
- Focus on staff safety rather than patient safety by Western Health post-discharge services
- Absence of family violence-specific safety planning and assessments
- Non-compliance with antipsychotic medication by the perpetrator since August 2013
- Failure to identify and respond to repeated threats and violent behaviour towards parents
- Inadequate training of health professionals in identifying elder abuse outside intimate partner relationships
Coroner's recommendations
- Adoption of minimum standards and core competencies in identifying family violence, conducting risk assessments and risk management practices in all mainstream and specialist mental health services (Royal Commission Recommendation 3)
- Establishment of specialist family violence advisors within major mental health and drug and alcohol services (Royal Commission Recommendation 97)
- Development of guidelines on family violence risks associated with discharging or transferring care of a person receiving mental health services (Royal Commission Recommendation 98)
- Training and development of psychiatrists and medical staff in responding to people with mental illness who perpetrate family violence (Royal Commission Recommendation 102)
- Commonwealth Government should specify that workers in community service sector must complete certified training in identifying and responding to family violence, with family violence as core rather than elective unit in training packages (Royal Commission Recommendation 154)
- Implementation of The Integrated Model of Care for Responding to Suspected Elder Abuse across health services, including workforce training, liaison officers, counselling services, and local prevention networks
- Health services should implement policies and procedures to support staff in navigating ethical issues when working with older people experiencing abuse
- Mental health services should employ family violence-specific risk assessment and safety planning tools when discharging or managing patients with history of violence towards family members
- Improved information sharing protocols between mental health, aged care, and community services regarding identified risks to discharged patients and their families
Full text
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