Finding into death of William Thomas Flanagan

Contributing factors

• Treatment-resistant schizophrenia with command auditory hallucinations
• Comorbid cardiac disease precluding ECT and clozapine
• Prolonged inpatient admission in acute unit inappropriate for chronic mental illness
• Restricted leave and environmental confinement increasing distress and frustration
• Proximity of psychiatric unit to railway station with ready accessibility
• Deficiencies in observation documentation system
• Lack of clear guidelines on use of perimeter restraint
• Risk observation records not linked to clear clinical rationale

Coroner's recommendations

1. Revision of the sight observation system to become patient-centred and linked to clinical rationale, functioning as an adjunct in detection of patient deterioration and assessment of dynamic patient factors
2. Implementation of standardised clinical handover procedures with structured processes
3. Development of clear procedures linking daily risk assessment to daily management strategies with explicit documentation of management plans
4. Improvement of clinical documentation standards including consistent entry timestamps, staff identification, and attendee recording at reviews
5. Development of guidelines on use of perimeter restraint (locking of unit doors) to support clinical decision-making