Finding into death of Duncan Stuart Sparke

Contributing factors

• Absconding from locked psychiatric unit via Door A/B security access points
• Delay in reporting missing person to police (approximately 2 hours)
• Inadequate security mechanisms on psychiatric ward exit doors at the time
• Patient distress regarding confinement and ongoing treatment
• Incomplete documentation and record-keeping in police missing person investigation
• Gaps in supervisor oversight and risk reassessment during police investigation
• Patient actively evading police detection
• Underlying major depressive illness with suicidal ideation

Coroner's recommendations

1. Record-keeping of decisions and actions undertaken in missing person investigations should be optimised
2. Tasking and allocation of missing person investigations must be documented by supervisors or work unit managers
3. Allocated tasks that remain incomplete at the end of a shift/day should be documented
4. Risk categorisation should be reconsidered/validated/documented in response to information generated by a missing person investigation
5. Periodic supervisor checks of missing person investigations should occur and be documented
6. Periodic review(s) of missing person investigations by Criminal Investigation Unit should occur and be documented
7. Victoria Police to implement database prompts requiring members to consider whether risk categorisation remains valid when adding new information to LEAP
8. Future coronial investigations should ensure complete records are compiled at an early date including statements of resource pressures, supervisor statements focused on risk assessments and task assignments, and inquiries of all relevant police regarding actions taken but not recorded
9. Coroner to work with Police Coronial Support Unit to devise appropriate brief request protocols for missing person investigations