Finding into death of Anthony Lansell Churches

Contributing factors

• Absconding from emergency department during high-activity afternoon period (2pm-4pm staff changeover)
• Lack of formal mental health assessment by ED mental health clinician upon arrival
• Absence of one-to-one observation despite suicidal risk with specific high-lethality plan
• No formal visual observation schedule or documentation of last observation time
• Failure to complete MHA124 notification form to police, leaving police unaware of urgency
• Lack of continuous observation of patient in high-visibility cubicle
• Patient's access to high-lethality means (cyanide) at home
• Neighbour dispute and PSIO making home unsafe refuge despite psychiatric risk

Coroner's recommendations

1. St Vincent's Health conduct a review of training programs (induction training for new ED staff and periodic training for ongoing ED staff) and any associated materials (hard copy and online) to ensure that they include comprehensive guidance about the response required in the event that a compulsory psychiatric patient absconds and highlights the importance, purpose and use of the MHA124 form when notifying police
2. St Vincent's Health consider the introduction of measures to improve observation of patients at risk of absconding from the ED during the afternoon change of shift (2pm-4pm)
3. St Vincent's Health provide an update about implementation of its mental health crisis hub including a comment on anticipated (or actual) improvements to patient supervision, absconding risk minimisation or other aspects of mental health management in the emergency department, and how these will be monitored and evaluated