Finding into death of MrJ

Contributing factors

• Acute behavioral disturbance secondary to substance intoxication and possible underlying mental illness
• Recent head injury with altered mental status
• Delayed mental health assessment due to prioritization of medical stabilization
• Insufficient security staffing in ED to prevent absconding
• Patient attempted to leave hospital during acute crisis
• Rapid deterioration in behavior on morning of death
• Possible disorientation and erratic behavior observed by witnesses after leaving hospital

Coroner's recommendations

1. Patients in ED who require mental health assessment should be referred at the earliest possible opportunity, even if a meaningful assessment cannot immediately occur
2. Collateral information from families should not contribute to significant delays in mental health assessment
3. Develop procedures requiring mental health risk assessments when patients present with mental illness or behavioral disturbance
4. Ensure mental health representatives attend code greys and undertake mental health risk assessment
5. Roster and base two security guards in ED at all times
6. Submit report to Chief Operating Officer regarding alternative entrance changes and security strategies for ED exit doors
7. Update code grey procedures to include mental health assessment documentation
8. Undertake annual audits of compliance with mental health and medical assessments post code grey