Finding into death of Mathew James Luttrell

Contributing factors

• Failure to engage Aboriginal cultural support during inpatient stay
• Failure to seek collateral information from family or treatment providers
• Inappropriate use of restrictive interventions without considering less restrictive alternatives
• Inadequate therapeutic relationship between clinicians and patient
• Incomplete discharge planning and follow-up
• Limited de-escalation skills and training among clinical staff
• Borderline personality disorder not recognised as mental illness within Mental Health Act framework by treating clinicians
• Absence of information-sharing agreement between hospital and community mental health provider MDAS
• Assessment Order used as vehicle to justify seclusion, restraint and sedation
• Lack of family involvement in treatment and discharge planning based on assumptions about intervention order

Coroner's recommendations

1. MDAS and Hospital to finalise a Memorandum of Understanding or other agreement relating to information-sharing to enable timely communication between MDAS and Hospital treating teams for common patients presenting in crisis
2. Hospital Director of Aboriginal Health to ensure cultural awareness training is appropriately resourced and rolled out to Mental Health Unit staff as priority, including locums and visiting clinicians, with recurrent refresher training
3. Director of Aboriginal Health and AHU staff to be consulted on all Hospital policies with view to improving cultural safety, and a system introduced requiring wards to inform AHU of Aboriginal patients and arrange for AHU staff to attend and introduce themselves
4. AHU to be resourced to ensure all staff have culturally appropriate clinical supervision arrangements where sought and agreed
5. All clinicians at Mental Health Services to be advised of AHU role upon induction and required to document steps taken to contact AHU for Aboriginal patients, including reasons if contact not made
6. Hospital to revise policies and procedures to clarify responsibility for collecting collateral information and timing, and that authorised psychiatrist or delegate must complete authorisations for restrictive interventions where available
7. Hospital to work with Spectrum to identify appropriate training for diagnosis and treatment of Borderline Personality Disorder addressing both long-term treatment and crisis presentations, to be mandatory for all community and inpatient mental health clinicians, included in induction and regularly repeated
8. Hospital to engage Victorian Equal Opportunity and Human Rights Commission to provide education to staff on Charter obligations
9. Hospital to engage Victorian Equal Opportunity and Human Rights Commission under Charter s41(c) to review policies and practices to strengthen compliance with Charter
10. Secretary Department of Health to ensure rollout of World Health Organisation QualityRights e-training across all designated mental health services as priority
11. Secretary Department of Health to continue implementation of Royal Commission recommendations in full, with update provided regarding recommendations 23, 26, 33, 35, 37, 40, 42, 44, 53, 54, and 55
12. Secretary Department of Health via Chief Psychiatrist to consider clarifying definition of 'seclusion' in Mental Health and Wellbeing Act to crystallise whether seclusion relates to confinement of patient(s) alone to an area where they cannot leave and whether presence of staff member affects the definition
13. Chief Commissioner of Police to consider including guidance in Victoria Police Manual for cases where police transport members of public to hospital or mental health facility on voluntary basis to provide all available handover information to assuming health facility with person's consent, replicating L42 form requirements
14. MDAS to identify appropriate staff who would benefit from training in management of Borderline Personality Disorder and seek appropriate training