JONES Eric

Contributing factors

• Drug overdose with methadone, opiates, and benzodiazepines
• Drug-induced delirium and confusion
• Agitation and multiple falls requiring restraint
• Inadequate staff knowledge of restraint safety risks
• Failure to provide manufacturer safety information to clinical staff
• Inadequate frequency of observation of restrained patient
• Inadequate documentation of observations
• No formal management plan for restrained patient
• Inadequate training and institutional protocols on restraint use

Coroner's recommendations

1. Victorian Department of Human Services to work with health networks to audit restraining equipment and ensure up-to-date manufacturer information is provided with all equipment
2. Develop standardized protocols for restraint use with comprehensive focus on risk management and illustrations of at-risk situations
3. Develop and regularly deliver standardized training packages for all staff on restraint use and risks
4. Implement systems requiring immediate reporting of all incidents and near-misses involving restraining devices to clinical management and hospital administration for investigation and assessment
5. Therapeutic Goods Administration to disseminate findings to all relevant agencies within Commonwealth and States
6. Therapeutic Goods Administration to research whether restraining devices require listing and whether national incident reporting system is needed