Finding into death of B L

Contributing factors

• inadequate post-discharge mental health follow-up from inpatient admission
• premature discharge from Acute Community Intervention Service after single phone contact
• failure to refer to Continuing Care Team despite meeting intake criteria
• lack of communication between Mildura Base Hospital and general practitioner
• discharge summary not provided to GP, preventing medication continuity
• inadequate documentation of second ED presentation on 9 March 2019
• no assessment of risk during second ED presentation
• escalating frequency of contact with mental health services and police not triggering re-evaluation
• absence of postvention services at time of treatment
• alcohol use on day of death
• recent relationship conflict and stressors

Coroner's recommendations

1. MBH implement a formal process to ensure communication with general practitioners regarding admission details, medication and follow-up arrangements for clients discharged from inpatient/acute settings
2. MBH implement a formalised process to ensure that discharge summaries are completed and provided to relevant stakeholders within a timely fashion
3. MBH ensure staff are aware of the requirements to document all clinical contacts relating to clients, with documentation to include adequate mental state examinations and descriptions of risk