Finding into death of Hari Prasad Dhakal

Contributing factors

• Schizophrenia and schizoaffective disorder
• Poor engagement with mental health services
• Persistent lack of insight into mental illness
• Cessation of antipsychotic medication in May 2024
• Chronically unstable mental state
• Possible active psychosis at time of death
• Brief psychiatric admission in May 2024 limiting clinical review
• Weak coordination between secondary and primary mental health services during prison transition
• Challenges in assessing suicide risk given poor engagement

Coroner's recommendations

1. Implement a process to support receiving consistent care information for patients on transition to Port Phillip Prison from a forensic mental health inpatient admission
2. Implement a standard to support ongoing risk mitigation and clinical care discussions between SVCHS and Forensicare
3. Build into routine practices the opportunity to review a forensic mental health patient's discharge summary on admission to Port Phillip Prison
4. Strengthen existing processes for when consumers do not attend scheduled outpatient appointments
5. Implement a 7-days post discharge follow-up process to align requirements in place at private prisons where the discharge location is within the same prison location
6. Stronger coordination between health services during transitions between secondary mental health and primary health services in custodial settings