Coroner's Finding: Peter Raven Fisher

Contributing factors

• Loss of contact with mental health services after discharge
• Missed antipsychotic medication appointment on 27 February 2007
• Discharge from hospital without Community Treatment Order despite recent suicide attempt
• Inadequate coordination and communication between GP and mental health team
• Loss of accommodation at Adelaide Street on 7 March 2007
• Untreated mental illness for five months prior to death
• No mechanism to ensure medication adherence without involuntary order
• Incomplete information provided to Mental Health Review Board regarding suicide attempt

Coroner's recommendations

1. The President of the Mental Health Review Board should review the way in which they obtain information relevant to mental health patients' involuntary status to ensure that they have adequate evidence on which to make a determination
2. The Royal Australian and New Zealand College of General Practitioners should encourage its members who administer regular depot antipsychotic medication to maintain active communication with their patients' mental health treating team, particularly when they fail to keep appointments
3. The Office of Housing should review the criteria for provision of public housing to mentally ill people who, despite having adequate income, are unlikely to obtain long-term private rental accommodation because of their illness and circumstances