Finding into death of Trajce Laboski

Contributing factors

• Failure by Emergency Department medical staff to make a section 30 assessment order despite having authority and clinical indications to do so
• Inappropriate placement of patient in unstaffed pink pod for mental health assessment
• Lack of communication and coordination between Northern Hospital ED and North Western Mental Health
• Understaffing of mental health services with only one EMHC on duty overnight
• Withholding information from patient about reason for waiting to maintain compliance rather than securing patient safely
• Absence of direct supervision for EMHC
• Patient's distress upon first being informed he would be admitted involuntarily
• Presence of unsecured stacked pallets adjacent to construction site near ED exit
• Proximity of construction site to ED exit

Coroner's recommendations

1. Melbourne Health North Western Mental Health and Northern Hospital undertake a review of actual wait times for Emergency Department Mental Health clinician assessments, especially out of business hours, to establish if the two-hour reasonable wait time is being achieved and address sustained variances.
2. Melbourne Health North Western Mental Health and Northern Hospital review the current service model of care for mental health patients in ED to identify opportunities to integrate patient care processes including: identify patient needs, increase communication of critical information, develop shared and comprehensive care planning, and prevent harm.
3. Northern Hospital Emergency Department in consultation with North Western Mental Health review the contemporaneousness and appropriateness of the current practice that removes medical practitioner responsibilities under the Mental Health Act 2014 and assigns them to North Western Mental Health clinicians, informed by: escalation processes in ED, understanding of sections 28-30 of the Mental Health Act, understanding of Mental Health Act safeguards and patient rights, and advice from the Chief Psychiatrist regarding section 30 obligations.