Finding into death of Thi Qui Tran

Contributing factors

• Extended unescorted leave granted on extreme heat day (37-40°C)
• Wearing heavy black jacket in hot conditions
• Antipsychotic medications (zuclopenthixol and olanzapine) that increase heatstroke susceptibility
• Schizophrenia diagnosis with recognised thermal dysregulation vulnerability
• Inadequate consideration of risk profile change when leave extended from 30 minutes to 8 hours
• No documented staff attempt to locate patient when overdue from initial 30-minute leave period
• Grace period protocol (allowing up to 10pm for AWOL notification) delayed alerting authorities

Coroner's recommendations

1. Services should develop heat health plans for vulnerable mental health consumers addressing safety in extreme weather
2. When leave is extended, risk profiles should be reassessed including consideration of clothing worn and access to food and fluids
3. Doctors should review leave arrangements for vulnerable patients when temperature is expected to exceed 30 degrees Celsius
4. Services should implement proactive approaches to postponing and cancelling leave during extreme heat events
5. Staff should receive training on thermal dysregulation risks in schizophrenia and antipsychotic-related heat sensitivity
6. Patients on combination antipsychotics should receive clear education about heat-related risks and appropriate clothing