Finding into death of Mr O
Deceased
Mr O
Demographics
47y, male
Date of death
2017-07-12
Finding date
2021
Cause of death
Hanging
AI-generated summary
A 47-year-old man with newly diagnosed schizophrenia died by hanging. He had presented with paranoid delusions and was engaged with mental health services in February 2017. Critical deficiencies were identified in the mental health service's response: family-driven contact patterns rather than proactive engagement; failure to engage his partner despite identifying her as a protective factor; extended gaps between contact (over 8 weeks at one point); delayed Community Treatment Plan preparation (13 weeks instead of 6-8 weeks); and inadequate clinical supervision. The treating psychiatrist directed fortnightly reviews, but the treating clinician struggled with engagement and never formally reported inability to meet this directive. No adequate supervision structures were documented. Although the patient was non-adherent to medication and reluctant to engage, more assertive outreach and structured supervision could potentially have prevented this preventable death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- Untreated schizophrenia with paranoid delusions
- Medication non-adherence
- Failure of mental health service to engage proactively
- Extended periods without contact between treating clinician and patient
- Failure to engage patient's partner despite identifying her as protective factor
- Delayed Community Treatment Plan (13 weeks instead of 6-8 weeks)
- Lack of adequate clinical and management supervision
- Poor coordination between mental health service and general practice
- Service staffing shortages
- Patient's reluctance to engage with mental health services
- Suicidal ideation with vague plan not adequately managed
Coroner's recommendations
- BHS develop a specific policy or procedure to address the importance of actively engaging family and responding to family concerns, consistent with the Victorian Chief Psychiatrist's guideline 'Working together with families and carers'
- BHS ensure that their procedure entitled 'Persons who are difficult to engage' incorporates information about the important skills that are required for these patients and ensure that staff are afforded training opportunities to improve their confidence and skills when working with difficult-to-engage patients, noting the work undertaken by Orygen in this area
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