Inquest into the Death of Carly Jean ELLIOTT

Contributing factors

• inadequate individual management plans
• inadequate risk management plans
• inadequate discharge planning
• failure to contact family members regarding discharge
• failure to involve carers in discharge decisions
• inadequate follow-up procedures
• fragmented care between service components
• overworked clinicians with insufficient resources
• time pressure preventing adequate clinical assessment
• inadequate communication with families
• inadequate security measures for involuntary patients
• non-compliance with medications
• missed psychiatric assessments
• consultant psychiatrist on leave
• inadequate procedures for longitudinal risk assessment
• inappropriate follow-up timing after discharge
• clinician did not see patient in person before discharge decision

Coroner's recommendations

1. Develop policies and procedures for implementation of Carer's Plans addressing: diagnosed condition and medication regime information; relapse prevention plan information; guidance on when to proactively re-engage with mental health services; individual needs and concerns of carers; support services available to carers; and patient consent and risk issues
2. Continue funding and resources to progress Stokes Review recommendations and Chief Psychiatrist's standards from planning to implementation stage
3. Establish formal 24-hour follow-up procedures after discharge (by telephone or face-to-face as appropriate)
4. Develop and implement policies requiring involvement of carers/families in admission and discharge planning
5. Establish procedures for efficient assessment of patients' longitudinal risk factors in crisis situations
6. Implement clear documentation requirements for risk management plans
7. Establish procedures for formal risk assessment following self-harm incidents
8. Develop integrated care procedures between CERT and ongoing psychiatric services
9. Establish security measures adequate for containing involuntary patients and raising immediate alerts if patients abscond
10. Create smoking areas within secure locked ward courtyards to avoid need for escorted ground access to unsecured areas
11. Implement personal duress alarms for staff monitoring involuntary patients
12. Develop policies for assertive follow-up of involuntary patients discharged directly to community
13. Establish mandatory policies for clinicians to contact families regarding discharge decisions
14. Implement State-wide Standardised Clinical Documentation suite with mandatory carer involvement fields
15. Develop policies addressing management of patients who decline follow-up
16. Establish resource allocation to prevent excessive clinician workload affecting quality of care