Inquest into the Death of Justine PAINTER

Contributing factors

• Failure of RPH nursing staff to read transfer documentation identifying absconding risk
• Absence of mental health risk assessment on admission to general medical ward
• Failure to allocate one-to-one nursing observation despite known high absconding risk
• Progressive unsupervised leave allowed after initial settling-in period
• Dismissal of concerns raised directly by guardian and residential facility staff
• Poor communication within Ward 8A between nursing and medical teams
• Assumptions that patient would return as she had done previously
• Absence of psychiatric liaison nurse review
• Placement in general gastroenterology ward rather than psychiatric ward despite complex psychiatric history
• Insufficient information provided in electronic bed management system at time of booking

Coroner's recommendations

1. All admissions and transfers of patient care must be accompanied by appropriate clinical handover with clinicians responsible for reviewing transfer records
2. Clerical staff to provide interfacility transfer records to admitting nurse for review before filing
3. For multi-day admissions from residential facilities, receiving staff must contact the facility to seek verbal clinician-to-clinician handover to verify information and identify risks
4. When patients convert from day admission to multi-day admission, hospital staff must recontact external facility for verbal handover due to inferred change in condition
5. Risk information for known regular patients should be flagged at the time of booking by the doctor arranging admission
6. Holistic assessment of patients incorporating all health issues (physical and psychiatric) should occur across all wards, not just geriatric services
7. Multidisciplinary admission forms should be implemented to ensure medical, nursing, and allied health input from the outset
8. Implementation of auditing processes to ensure standards are met for comprehensive holistic patient care
9. Greater emphasis on psychiatric liaison nurse review for patients with known mental health history admitted to general medical wards