Inquest into the Death of Theodore Herbert Eric JOHANSEN

Contributing factors

• Active suicidal ideation with detailed plan not previously disclosed
• Concealment of significant family history of mental illness and suicide by deceased
• Assessment occurred on the deceased's brother's birthday (unrecognised by clinicians)
• Lack of collateral information from family or treating psychologist
• Patient refusal to allow discussion with family members due to embarrassment and custody concerns
• Deceased's reassuring demeanour and presentation masking underlying risk
• Return to stressful home environment immediately after discharge
• Lack of family involvement in discharge planning and risk communication
• Incomplete psychiatric assessment documentation

Coroner's recommendations

1. Ensure comprehensive documentation of all psychiatric assessments and management plans in medical records
2. Implement procedures to record in nursing documentation when psychiatric liaison nurses or doctors request notification of patient discharge, to ensure follow-up communication with family occurs
3. Use electronic flagging systems in ED patient tracking when discharge communication is required
4. Develop and adopt scripted wording for ED staff to encourage patients to remain for psychiatric assessment, avoiding language such as 'putting on forms' which may cause patients to become guarded and less willing to disclose symptoms
5. Maintain and strengthen policy requiring consultation with consultant psychiatrists when patients are referred by medical practitioners for admission or assessment
6. Encourage more flexible approaches to obtaining collateral information, including broader discretion to breach confidentiality when essential risk factors may be omitted by the patient
7. Improve access to psychiatrists for face-to-face assessment in ED settings
8. Consider designated areas or streaming for mental health patients in ED to allow more comprehensive assessment in appropriate environment