Finding into death of Harley Robert Larking

Contributing factors

• Absconding from Low Dependency Unit via easily scalable courtyard fence
• Staff shortage on day of trial (no late shift nurse)
• Predictable observation schedule (30-minute intervals) allowing undetected departure
• Only two weeks on clozapine (titration phase, not yet optimal)
• Known fence risk identified April 2015 but not remedied by May 2016
• Ambiguous and unclear missing patient policies at NWMHS
• Staff unfamiliar with missing patient procedures and Kelly memo 2013
• Inadequate whole-staff cultural competence training despite liaison officer
• Brief phone call to police without confirmation of receipt or recording of officer details
• Police failure to record or act on missing person call

Coroner's recommendations

1. Review policy and procedures for monitoring involuntary patients in line with Department of Health 2013 nursing observation guidelines, with focus on unpredictability of observation timing to prevent routinisation
2. Implement secure electronic transmission process to replace facsimile system for missing patient notifications to police
3. Enter both actual and attempted absconding instances in Riskman and reconcile with Victoria Police records
4. Specify that compulsory inpatients absconding for more than 15 minutes be reported to police (absent documented treating psychiatrist rationale otherwise) and recorded in Riskman
5. Review and rationalise missing persons policies across Melbourne Health to ensure plain English, consistency, and clarity of steps and timeframes
6. Provide regular staff training on missing/absconded person policies with audits to ensure appropriate reporting to external agencies
7. Implement Aboriginal cultural competency training for all inpatient psychiatric staff including focus on working with Koori workers and culturally informed treatment planning
8. Northern Health to establish system for prioritising environmental risk remediation with escalation to governing body if risks not managed timely
9. Office of Chief Psychiatrist to review other public mental health inpatient units regarding Aboriginal mental health liaison officer availability and cultural competence embedding