Finding into death of Helen Maria Bryce

Contributing factors

• Severe depression with anxiety and possible psychotic features
• Two recent suicide attempts prior to admission
• Deficient leave approval process with inadequate direct consultant assessment
• Over-reliance on assessment by junior doctor with less than 5 months psychiatric experience
• Consultant psychiatrist's assessment made 'on the papers' without direct patient assessment on day leave was approved
• Failure to obtain and adequately communicate family concerns about patient's reluctance to return to ward after previous leave
• Inadequate communication of leave conditions and supervision requirements to primary carer
• Failure to provide crisis planning or escalation instructions to carer
• Impaired insight into illness with repeated denial of suicidal ideation masking ongoing suicidal thoughts

Coroner's recommendations

1. Development of standardized and structured leave process with standard tools for gathering and documenting risk information about patient and carer capacity
2. Provision of information to patient and carers about level of supervision required, medication administration, illness trajectory, early warning signs, contact numbers and escalation procedures
3. Implementation of active communication between health service and patient/carer during leave
4. Assessment of patient access to lethal means and management of risk
5. Implementation of written leave plans containing crisis management information provided to all carers