Inquest into the Deaths Alma Street Centre

Contributing factors

• No adequate individual management plans
• No adequate risk management plans
• No clear discharge plans
• Failure to contact family members regarding discharge despite family concerns
• Failure to explore patient's reasons for seeking early discharge
• Inadequate follow-up arrangements post-discharge
• Inadequate communication with families
• Fragmented care between different service components
• No integration of crisis assessment team findings into ongoing care
• Clinician time pressures and workload
• Absence of policies to prompt carer involvement
• Failure to address longitudinal risk factors
• Consultant psychiatrist unavailability/leave
• Inadequate security measures for involuntary patients
• No immediate alert system for absconsion from secure areas

Coroner's recommendations

1. The Western Australian Department of Health should develop policies and procedures for implementation of Carer's Plans addressing: information concerning diagnosed condition and medication regime; information relevant to relapse prevention plan; information relevant to guidance as to when to re-engage with mental health services; information relevant to individual needs and concerns of carers; and information relevant to support services available to carers
2. The Western Australian government should continue its efforts to provide funding and resources required to progress the Stokes Review recommendations and Chief Psychiatrist's standards from the planning stage to the implementation stage
3. Implementation of Assessment and Treatment Teams (ATT) that combine crisis response with case management capabilities to avoid fragmentation of care
4. Development and implementation of mandatory state-wide standardized clinical documentation (SSCD) including treatment, support and discharge plans with fields for carer/support person involvement
5. Implementation of Chief Psychiatrist guidelines on communicating with carers and families
6. Introduction of personal duress alarms and immediate alert systems for involuntary patients
7. Secure smoking areas within locked wards to prevent absconding
8. Enhanced security measures for controlled court yard access in psychiatric facilities
9. Mandatory follow-up contact within 24 hours of discharge for high-risk patients
10. Development of risk assessment and management standards for mental health services
11. Development of transfer of care standards
12. Development of seclusion and bodily restraint standards
13. Development of consumer and carer involvement in individual care standards
14. Development of assessment standards
15. Development of policies on management of patients who decline follow-up
16. Development of physical care of mental health consumers standards