Inquest into the Death of Aaron Luke PRISGROVE

Contributing factors

• depression
• alcohol abuse and dependency
• recent relationship breakup
• adjustment reaction following employment termination
• high-risk assessment but downgraded monitoring level
• patient allowed to rest in remote, difficult-to-monitor room
• military holdall bag with handles returned to patient after property search
• ward layout unsuitable for observation
• unusual ward activity and high patient emotional arousal
• insufficient time for doctor assessment before suicide attempt

Coroner's recommendations

1. Newly admitted patients should be maintained at the same level of observations as was in place at the transferring hospital (implemented post-death)
2. Not returning the holdall bag to patients, keeping newly admitted patients in the day area, and maintaining one-to-one special until medical assessment should be considered as policy (implemented post-death)
3. Review of the model of care for nursing
4. Audit of documentation of PRN medication authorisation (implemented post-death)
5. Safety Plan should be used to engage with patients and formulate collaborative risk management plans
6. Improved facilities for acute mental health patients (Smith Ward was unsuitable and being considered for closure)
7. Greater priority and resources for mental health services in Western Australia
8. Address ward layout and observation capabilities (improvements with mirrors and cameras underway)