Inquest into the Death of Frances May COOPER

Contributing factors

• decision to allow unescorted leave for an involuntary patient with active psychotic symptoms and absconding risk
• gaps in community mental health care following discharge from Norseman in May 2011
• informal and poorly documented risk assessment processes
• failure to involve family in care planning despite explicit family concerns about safety
• lack of multidisciplinary team involvement
• lack of secure smoking area due to Department of Health smoking prohibition on hospital grounds
• poor medication compliance and cannabis use contributing to mental state deterioration
• inconsistency between psychiatrist discharge recommendations and actual discharge decisions
• lack of continuity of psychiatric care (four different psychiatrists in 2010-2011)
• limited psychiatrist oversight of nursing decisions regarding leave
• reliance on patient's promise to return despite known history of dishonesty and poor insight

Coroner's recommendations

1. Development of a process to transfer case management within the Goldfields Mental Health Service
2. Development of improved processes to transfer information with patients including daily communication between Mental Health Inpatient Service and Community Mental Health Service
3. Development of processes to ensure case management of patients including follow-up of overdue medication
4. Development of a process to ensure information from family and carers is documented and included in care planning
5. Development of a standard process for risk assessment and documentation over the course of treatment
6. Development of training for mental health staff, ED staff and hospital coordinator staff in mental state examination as annual core competency
7. Development of a process for recording leave of absence of involuntary patients from the mental health unit
8. Ensuring treatment planning and review includes the treating psychiatrist and is consistent with the psychiatrist's documented intentions
9. Review of the procedure for discharge of patients from the mental health unit