Finding into death of Kai Wesley Wu

Contributing factors

• First-episode psychosis with treatment-resistant schizophrenia
• Medication side-effects causing significant distress
• Impaired judgment due to mental illness
• Patient left unsupervised during escorted leave when expecting supervision
• Lack of explicit documented communication with father regarding supervision requirements

Coroner's recommendations

1. Develop explicit processes and documentation standards for communicating leave conditions and supervision expectations to carers, ensuring clarity that escorted leave requires constant supervision and that carers understand this requirement
2. Implement mandatory documentation in progress notes of discussions with carers about leave conditions, including confirmation that the carer understands the supervision requirements
3. Review leave pathway procedures to ensure compliance with Office of the Chief Psychiatrist guidelines and consider whether additional safeguards are needed for high-risk patients, particularly regarding single-person supervision
4. Develop a consistent approach to recording mental state examinations and leave authorization by the assessing clinician rather than relying solely on verbal handovers
5. Review the adequacy of current processes for assessing and documenting whether family carers understand and can safely implement supervision expectations for patients on escorted leave