Finding into death of Michael Stephen Delaney
Deceased
Michael Stephen Delaney
Demographics
37y, male
Date of death
2020-04-06
Finding date
2023-06-06
Cause of death
Plastic bag asphyxia
AI-generated summary
Michael Delaney, a 37-year-old man with treatment-resistant schizophrenia, died by plastic bag asphyxia while residing at supported independent living accommodation. He had multiple suicide attempts and was under the care of various mental health services. Key clinical lessons include: (1) ensure direct communication between treating psychiatrists and inpatient mental health facilities when patients are assessed during admission, particularly regarding treatment recommendations; (2) clarify responsibility for referrals between services to prevent care gaps; (3) communicate risk assessment findings and recommendations between all treating services; (4) ensure safety plans are actively followed rather than subject to staff discretion; (5) coordinate care between private and public mental health services to prevent fragmentation. While individual service care was appropriate, poor communication and coordination meant that critical information about Michael's need for specialist multidisciplinary input and community care unit admission was not shared with the inpatient facility, potentially affecting discharge planning.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- Treatment-resistant schizophrenia with severe symptoms
- Multiple prior suicide attempts
- Poor communication between The Victoria Clinic and Dr P.-Huezo regarding assessment recommendations
- Unclear responsibility for referral to Peninsula Mental Health Services following discharge from private inpatient facility
- Lack of direct communication between PMHS and The Haven after Michael's suicide attempt on 26 March 2020
- Inconsistent application of safety plan following 26 March suicide attempt
- Discharge from private inpatient facility without confirmed ongoing specialist psychiatric care
Coroner's recommendations
- Healthscope should develop a policy or procedure whereby admitting psychiatrists and/or The Victoria Clinic staff communicate directly (subject to consent) with external health professionals involved in the care of current inpatients to ascertain the outcome of any assessment and/or treatment recommendations
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