Finding into death of Antonio D'Augello

Contributing factors

• Non-compliance with antipsychotic medication
• Deterioration in mental state following medication cessation
• Acute psychosis with impaired judgement and insight
• Lack of inter-service communication between Goulburn Valley Health and Bendigo Health
• Inadequate family engagement and collateral information gathering
• Absence of psychiatrist review for four months
• Discharge planning reliant on patient refusing treatment
• Inadequate assessment of patient vulnerability and family capacity to supervise
• Falls and collapses in preceding weeks suggesting physical deterioration

Coroner's recommendations

1. Goulburn Valley Health update their Working with Carers clinical practice guideline to reflect the 2018 Chief Psychiatrist Guideline, Working Together with Families and Carers and provide education of these changes to the Acute Response Team
2. Goulburn Valley Health and Bendigo Health Mental Health Service develop an agreement or understanding, accessible to clinical services which specifies that where possible timely and direct communication with the treating team of a case managed client of either's services occurs, with the intent of gathering collateral information to inform assessments and before treatment planning is completed
3. Bendigo Health Mental Health Service review the requirement for the timely escalation of the care of a community case managed client who is experiencing a deterioration in mental state to facilitate timely access to a face to face review by a psychiatrist