Finding into death of Erol Elmas

Contributing factors

• acute psychotic relapse of schizoaffective disorder
• inadequate vital signs monitoring during seclusion
• failure to escalate high respiratory rates to emergency response
• inability to obtain full physical observations due to patient violence risk
• lack of standardised observation charts for seclusion monitoring
• risk of violence toward staff preventing close physical examination
• heavy sedation masking physical deterioration
• possible respiratory obstruction from blanket and underwear around neck (not definitively excluded)

Coroner's recommendations

1. Forensicare to establish a standardised system for management of physical health including monitoring, detection of deterioration, escalation pathways, policies, procedures and training for staff
2. Forensicare to require use of Standard Observation Chart for all physical observations including during seclusion episodes, and revise the chart for applicability to both hospital and prison services
3. Provide specific instructions on requirements for medical examination during seclusion episodes
4. Remove all risk items prior to seclusion placement and escalate safety concerns related to clothing to formulate risk management plans
5. Implement detailed escalation pathway requiring escalation to Clinical Administration if staff unable to enter seclusion due to risk, with mandatory reporting to Executive leadership if Authorised Psychiatrist unable to enter within four hours
6. Monitor and record respirations during seclusion observations
7. Use non-contact physical observation tools outlining airway, breathing, circulation, disability and exposure indicators
8. Ensure vision to seclusion room is not obstructed; escalate if vision compromised