Inquest into the Death of Blinkhorn, Leah Christine

Contributing factors

• personality disorders with impulsivity and unpredictability
• depression with strong death wish
• evasiveness during telephone assessment
• failure to obtain clear details of substances taken
• assumption patient had complied with advice to attend hospital
• failure to consider police welfare check despite concerning features
• inadequate telephone crisis assessment training
• prior history of medication stockpiling for overdose

Coroner's recommendations

1. Staff likely to respond to telephone inquiries at Perth Clinic, particularly at night, are trained to make clinical assessments on the telephone as well as normal risk assessments in their day to day work experience. There are a number of emergency telephone operators who train call receivers in appropriate assessment.
2. River Ward, as the ward receiving telephone calls from the switchboard after hours always be staffed by nurses trained in telephone assessment.
3. Perth Clinic investigate the feasibility of a tracer call facility with the Police or more simply provide their service provider information next to telephones capable of receiving outside calls with instructions about timing the commencement and duration of calls where a concern may arise as to the safety of the caller.