Finding into death of Jack David watson

Contributing factors

• Inadequate transition of care between mental health services
• Failure to establish contact with patient following referral
• Lack of escalation to senior clinician after failed contact attempts
• No family contact or welfare checks by Alfred Health
• Patient discharge from inpatient unit despite moderate-to-high suicide risk
• Patient's reported plan to manipulate treating doctors not adequately communicated or acted upon
• Discrepancy between patient's calm affect and documented ongoing suicide risk not sufficiently weighted in discharge decision
• Referral lacked specific timeframe and urgency indicators
• No face-to-face assessment post-discharge despite high-risk profile
• Relationship breakdown and separation trigger
• Isolation following relocation and disengagement from local mental health services

Coroner's recommendations

1. Ballarat Health Services should amend the 'Transfer between another Area Mental Health Services - Community Services' section of the Patient Transfer Protocol to explicitly require that referral discussion address a recommended timeframe for the receiving service to see the patient, including the relative urgency of a face-to-face interview as opposed to telephone contact, with these matters documented in information sent to the receiving service