Inquest into the Death of Mark Quenton FLEURY

Contributing factors

• paranoid schizophrenia with persistent delusions
• poor insight into mental illness
• erratic medication compliance
• medication change from risperidone to aripiprazole without anticipated benefit
• refusal to allow family involvement in care
• patient minimisation and concealment of symptoms
• fragmented family communication
• difficulty obtaining timely collateral information from family
• lack of crisis management plan
• misdirection of emergency phone call
• after-hours service gaps

Coroner's recommendations

1. Implementation of collaborative crisis management plans (consumer care crisis and relapse plans) shared with patients, families and services to emphasise access to voluntary admission during crisis
2. Development of separate crisis plans for carers and family members in cases where consumers refuse their involvement in care, containing contact information and escalation pathways including Care Call number
3. Consideration of implementing a carer support advocate service to provide information, support and advocacy for carers and families, distinct from peer worker roles
4. Routine convening of family conferences in early stages of treatment to pool family information and clarify communication pathways, even when patients refuse direct involvement
5. Implementation of systems to appropriately direct incoming calls relating to community mental health patients to correct clinical teams
6. Improvement of after-hours mental health service availability and accessibility with clear communication pathways for families
7. Enhanced electronic medical record systems to ensure timely and comprehensive documentation
8. Greater effort to obtain collateral information from family members when assessing risk, particularly when family concerns diverge from patient self-report
9. Consultation with mental health consumer and carer support experts regarding feasibility of dedicated carer advocacy services