Finding into death of Jacob William Kennedy

Contributing factors

• Accumulation of multiple sedating medications (methadone, benzodiazepines, antipsychotics, pregabalin)
• Failure to comply with mandatory monitoring recommendations for sedated patients
• Inadequate vital signs monitoring despite heavy sedation
• Concurrent prescription of benzodiazepines (clonazepam and diazepam) without clear management plan
• Multiple antipsychotic drugs administered simultaneously (Olanzapine, Haloperidol, Chlorpromazine)
• No ECG performed despite guideline requirements
• Prone positioning on mattress on floor without close supervision
• Visual observation only through window/door from distance
• No interaction or arousal attempts during afternoon/evening sedation

Coroner's recommendations

1. The Medical Board of Australia, supported by AHPRA, should develop guidelines for treating clinicians in inpatient psychiatric units regarding prescription and administration of multiple medications with sedative effects, including admonishment of cumulative effects
2. The Medical Board of Australia, supported by AHPRA, should implement policy or protocol admonishing clinicians of the importance of adhering to health service provider guidelines for close and frequent monitoring of sedated patients until ambulant
3. The Nursing and Midwifery Board of Australia should implement policy or protocol admonishing nursing staff of the importance of adhering to health service provider guidelines for close and frequent monitoring of sedated patients until ambulant
4. The Medical Board of Australia, supported by AHPRA, should consider implementing policy or protocol advising clinicians to consider benefits of using an oximeter to monitor sedated patients in inpatient psychiatric units
5. The Medical Board of Australia, supported by AHPRA, should develop guidelines reflecting the use of an oximeter as an achievable, practical and reasonable measure for monitoring sedated patients in inpatient psychiatric units
6. Peninsula Health should review its policy or protocol to ensure compliance with Monitoring Recommendations in its Guideline mandating vital sign observations for sedated patients
7. Peninsula Health should initiate and undertake regular staff training measures for mental health care workers to ensure enforcement of a uniform monitoring regime for vital signs of sedated patients
8. Peninsula Health should undertake an external review of all policies and training relating to culturally competent and safe care, led by an external First Nations-identified individual or organisation, and implement recommendations
9. Peninsula Health should introduce and make publicly available annual compliance monitoring for cultural competency and safety training, and statistics concerning complaints about such care