Inquest into the Death of Michael Ronald THOMAS

Contributing factors

• inadequate individual management plans
• inadequate risk management plans
• inadequate risk assessment documentation
• failure to contact next of kin before discharge
• rushed clinical decision-making
• failure to adequately explore reasons for patient requests
• inadequate follow-up post-discharge
• lack of coordination between services
• fragmented care delivery
• inadequate communication with families
• inadequate security measures for involuntary patients
• absence of formal policies for carer involvement
• staff workload and resource constraints
• failure to consider longitudinal risk factors
• early discharge without adequate assessment
• inadequate supervision of junior staff

Coroner's recommendations

1. Develop policies and procedures for implementation of Carer's Plans addressing patient consent, risk issues, diagnosed condition, medication regime, relapse prevention, re-engagement guidance, individual carer needs, and available support services
2. Continue funding and resources to progress Stokes Review recommendations and Chief Psychiatrist standards from planning to implementation stage
3. Implement 24-hour follow-up contact (minimum telephone call) post-discharge for high-risk patients, particularly involuntary patients
4. Develop policies and procedures to support staff in contact with family members regarding admissions and discharges
5. Implement procedures for clinicians to systematically consider patients' longitudinal risk factors
6. Establish integrated crisis assessment and treatment services to avoid fragmentation (Assessment and Treatment Team model)
7. Develop procedures for clearly documenting discharge planning discussions and agreements with patients and families
8. Implement formal risk assessment documentation following all significant self-harm or suicide attempts
9. Improve security infrastructure for involuntary patients including secure smoking areas within locked wards and personal duress alarms for staff
10. Require psychiatric review on same day following significant self-harm or suicide attempts, not delayed over weekends
11. Ensure adequate face-to-face assessment by senior clinicians before discharge of high-risk involuntary patients
12. Implement structured clinical judgement tools for suicide risk assessment
13. Address staff resource constraints and workload to prevent rushed clinical decision-making