Inquest into the Death of Melanie Reanna TREGONNING

Contributing factors

• failure to communicate critical information from GP to ED staff
• failure to communicate ambulance clinical observations to ED staff
• inadequate psychiatric assessment in ED
• on-call psychiatrist did not attend ED for face-to-face assessment
• miscommunication between junior RMO and psychiatrist about care plan
• unavailable psychiatric liaison nurse due to family emergency
• patient redirected to wrong facility due to catchment area confusion
• ED environment causing additional distress to patient
• lack of psychiatric resources and beds
• systemic failures in information transfer between departments

Coroner's recommendations

1. Priority should be given to commissioning a Mental Health Observation Area at Fiona Stanley Hospital Emergency Department, similar to the model at Sir Charles Gairdner Hospital, to provide a therapeutic environment for mental health patients awaiting assessment
2. Junior doctors in the ED should continue to be reminded of the importance of requesting and reviewing St John Ambulance Patient Care Records, both to identify that a patient arrived by ambulance and to access critical clinical information
3. Mental health emergencies should be treated as seriously as any other medical emergency with appropriate resources directed to ensuring treatment by properly trained staff in appropriate therapeutic environments
4. The protocols and procedures regarding the assessment of mental health presentations in ED should be reviewed and clarified to ensure that when an RMO seeks input from a psychiatric professional, the psychiatrist attends for a face-to-face assessment rather than providing advice solely by telephone
5. Additional resources should be invested in the mental health system generally, including adequate mental health beds, properly trained psychiatrists and mental health professionals available 24 hours, and appropriate assessment areas in hospital EDs