Finding into death of Melissa Gaultier

Contributing factors

• Premature discharge from psychiatric hospital less than 24 hours after admission
• Failure to observe patient adequately before discharge decision
• Disregard of explicit warnings from referring hospital about need for psychiatric assessment before leave
• Lack of proper risk assessment prior to granting leave on 17 April 2017
• Failure to conduct mental state assessment before leave
• Inadequate documentation of leave entitlements and risk assessments
• Non-compliance with visual observation policy requirements
• Lack of clear processes for staff regarding leave management
• Absence of psychiatric continuity of care during transfer from Monash Health
• Easter period public holiday staffing arrangements affecting continuity of care
• Inadequate handover process - receiving psychiatrist did not become treating clinician
• Failure to escalate care when risk increased on 15 and 17 April 2017
• Possible diabetic ketoacidosis affecting cognitive function at time of death

Coroner's recommendations

1. Latrobe Regional Health implement a patient continuity of care transfer admission policy for its inpatient mental health ward, ensuring that appropriately qualified clinician(s)/inpatient consulting psychiatrist receiving handover details from another hospital are rostered and available to continue with that patient's care on admission