Finding into death of Garry Mark Wise

Contributing factors

• Non-compliance with antipsychotic medications
• Chronic schizophrenia with severe auditory hallucinations
• Alcohol dependence and daily heavy alcohol use
• Inadequate acute risk assessment despite clear warning signs
• Failure to escalate suicidal ideation and access to means
• Poor communication of critical risk information between services
• Delayed case manager contact following referral
• Lack of formal escalation protocol when client reported rope in room and suicidal thinking
• Gap between non-acute community mental health program capacity and client's high-risk clinical needs

Coroner's recommendations

1. To improve the safety of clients of the Bolton Clarke Homeless Persons Program and provide the program nurse clear and appropriate contact points for early escalation of concerns, the HPP develop and document a plan with clients as part of assessment that: (i) provides the client with a documented list of contacts for situations in which they feel unsafe or at increased risk; (ii) identify people the client agrees to have contacted by the Program nurse in case of an increase in concerns for the client's safety; and (iii) the plan is reviewed regularly and updated when circumstances change.