Inquest into the Death of Ruby Natasha NICHOLLS-DIVER

Contributing factors

• inadequate individual management plans
• inadequate risk management plans
• inadequate discharge planning
• failure to contact carers/families
• failure to comprehensively explore patient reasons for discharge requests
• inappropriate reliance on patient assurances of safety
• inadequate longitudinal risk assessment
• fragmented care between different services
• inadequate follow-up after discharge
• failure to escalate to senior psychiatrists when indicated
• failure to refer to emergency services when patients expressed suicidal ideation
• inadequate security measures for involuntary patients
• insufficient staff resources and high caseloads
• failure to document formal risk assessments
• poor integration between CERT and ongoing care services
• discharge of involuntary patient directly to community without appropriate follow-up timeframe
• inadequate procedures for managing patients on escorted ground access

Coroner's recommendations

1. Develop policies and procedures for implementation of Carer's Plans addressing patient consent and risk issues, including information on diagnosed condition, medication regime, relapse prevention plan, when to re-engage with services, carer needs, and support services available
2. Continue funding and resources to progress Stokes Review recommendations and Chief Psychiatrist standards from planning stage to implementation stage
3. Implement procedures to ensure carers/families are involved in admission and discharge planning
4. Develop procedures to ensure longitudinal risk factors are adequately considered in clinical assessments
5. Implement formal risk assessment and management procedures following any self-harm incidents
6. Establish clearer documentation standards for escorted leave conditions and supervision requirements
7. Implement personal duress alarm systems for staff managing involuntary patients on ground access
8. Establish follow-up within 24 hours (at minimum by telephone) after patient discharge from hospital, particularly for high-risk patients
9. Develop policies distinguishing follow-up requirements for involuntary patients discharged directly to community versus voluntary patients
10. Improve security measures in courtyard areas to prevent absconding by involuntary patients
11. Establish smoking areas within secure areas of locked wards to minimize risk of absconding
12. Implement integrated Assessment and Treatment Team model to replace fragmented CERT services
13. Develop policy on management of patients who decline follow-up or do not attend appointments
14. Ensure psychiatric registrars conduct face-to-face reviews before discharge decisions, especially when carers express concerns
15. Establish procedures for immediate escalation when patients express suicidal ideation by telephone
16. Implement State-wide Standardised Clinical Documentation prompting clinician consideration of carer involvement