Inquest into the Death of Paul STRANGE
Deceased
Paul STRANGE
Demographics
30y, male
Coroner
Coroner Jenkin
Date of death
2016-12-09
Finding date
2019-09-27
Cause of death
ligature compression of the neck (hanging)
AI-generated summary
Paul Strange, aged 30, died by suicide through ligature compression of the neck eleven days after discharge from Royal Perth Hospital (RPH) for depression with chronic suicidality. He had a documented history of multiple suicide attempts by strangulation and was initially assessed as high risk. Critical clinical failures included: failure to document a safety plan despite high-risk status; inadequate family involvement despite demonstrated protective factors and family requests; failure to enact discharge referrals to community mental health services; discharge without any follow-up arrangements; and failure to provide family with basic safety information about post-discharge vulnerability. A medication change occurred four days prior to discharge despite fluctuating mental state. The deceased was not detected to be taking prescribed quetiapine at time of death, worsening untreated anxiety and impulsivity. The coroner found care suboptimal but could not conclusively establish preventability, noting suicide's inherent unpredictability while emphasising systemic failures in discharge planning, documentation, and family engagement.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- inadequate discharge planning and execution
- failure to document safety plan despite high-risk status
- failure to make referral to community mental health services
- inadequate family involvement and communication
- medication changed four days prior to discharge
- no documented safety information provided to family at discharge
- poor communication and documentation of patient/family preferences regarding care involvement
- high-risk post-discharge period with no follow-up
- out-of-area admission to unfamiliar hospital
- poor quality medical record documentation
- medication non-compliance (quetiapine not detected at time of death)
- inadequate risk assessment following self-harm incident on 15 November 2016
Coroner's recommendations
- EMHS amend Care Coordination in Mental Health policy to require discharge consumers receive appointment cards with dates and times of all arranged service appointments
- EMHS amend policy to require discharge summaries include: emergency services contact details, out-of-hours contact numbers, Mental Health Emergency Response Line, details of arranged appointments, re-entry process information, and clinician/care coordinator name
- EMHS amend discharge procedure so discharge summaries cannot be printed or patient discharged until appointments made and handover with receiving services completed (except in exceptional circumstances)
- EMHS develop strategies to ensure staff familiarity with key policies including providing new staff top 10 policy list and discussing policies at regular team meetings
- EMHS examine feasibility of establishing post-discharge follow-up team, especially for out-of-area admissions, to bridge gap between discharge and receiving service acceptance
- Office of Chief Psychiatrist issue guidelines regarding communications with family/support persons when competent voluntary patient refuses family involvement, and consider abridged practice note version
Full text
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