Inquest into the Death of Jesse Richard DELLAR

Contributing factors

• adolescent placed on general ward rather than secure psychiatric ward after reporting suicide attempt
• inadequate documentation of observation level changes
• orderly removed from line-of-sight supervision before medical review on morning of death
• delayed medical review by admitting doctor after reported hanging attempt
• volatile mood and impulsive suicidal behaviour in adolescent with incomplete resolution of psychosocial stressors
• limited specialist psychiatric input overnight and early morning hours
• youth allowed unsupervised movement around hospital despite recent suicide attempt
• relationship conflict with girlfriend and family stressors remained unresolved

Coroner's recommendations

1. Implementation of adolescent and suicide risk assessment tools with escalation response matrix
2. Increased liaison between psychiatric services and hospital, particularly Child and Adolescent Health Service (CAMHS)
3. Provision of mental health upskilling to general ward staff
4. Review of availability of nicotine inhalers as therapy to decrease need for ward exits
5. Automatic transfer to secure mental health ward for patients reporting serious suicide attempts, with 24-hour chaperone supervision until psychiatric review, removing clinical discretion in such cases
6. Standardised documentation forms for children and adolescents including formal recording of risk assessments and authorisation for changes to observation levels
7. Better integration of psychosocial interventions alongside pharmacological treatment
8. Improved communication and liaison with adolescent psychiatric units in Perth (Bentley Adolescent Unit)
9. Involvement of family and support networks in multidisciplinary treatment planning with supportive counselling provided
10. Enhanced psychiatric nursing support and availability, particularly outside standard business hours
11. Structured coordination between Albany Hospital and services such as Headspace