Finding into death of RW C
Deceased
RCW
Demographics
43y, male
Date of death
2020-02-06
Finding date
2023-12-13
Cause of death
exsanguination from incised wounds to the arms - self inflicted
AI-generated summary
A 43-year-old man with schizophrenia, PTSD, and methamphetamine use died from exsanguination following self-inflicted incised wounds to both arms. He had been discharged from psychiatric inpatient care on 1 February 2020 after a 14-day admission for a previous suicide attempt, placed on a Temporary Treatment Order with long-acting injectable antipsychotic medication. Follow-up by the community team was limited to two brief phone calls for appointment arrangement purposes, without documented assessment of suicidal ideation, psychotic symptoms, or illicit drug use—all high-risk factors. When he missed a scheduled psychiatrist appointment on 5 February, no face-to-face reassessment was undertaken. The coroner found the post-discharge follow-up fell below his needs during a high-risk transition period, though it cannot be definitively stated this would have prevented his death. The coroner noted that seeking collateral information from his family, who had observed him to be withdrawn and angry post-discharge, may have identified increased risks warranting more assertive community treatment.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- schizophrenia with ongoing psychotic symptoms at discharge
- recent suicide attempt (January 2020)
- methamphetamine use
- post-traumatic stress disorder
- command hallucinations
- inadequate post-discharge community follow-up
- missed psychiatrist appointment without adequate reassessment
- lack of collateral information from family
- delayed ambulance response (92 minutes)
Coroner's recommendations
- NorthWestern Mental Health should consider revising policies, guidelines, or call scripts for community-based staff supporting patients discharged from inpatient units, particularly following recent suicide attempts and with history of illicit drug use, to include: (i) direct enquiries regarding existing symptoms and illicit drug use; and (ii) seeking collateral information from family members involved in treatment and discharge planning to inform clinical decision-making
- Ambulance Victoria to develop a baseline 'rapid assessment' workflow script for triage services to determine patient's conscious state, breathing status, and presence of uncontrolled bleeding (implemented)
- Ambulance Victoria to improve quality and consistency of assessment summary used by Secondary Triage Practitioners with opportunity for caller to confirm accuracy and provide additional information (implemented)
- ESTA scripts for estimated time of arrival updates to be reviewed for accuracy (implemented)
Full text
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