Inquest into the Death of Petya Evgenieva PETROVA-CIZEK

Contributing factors

• failure to remove shoelaces on admission despite policy
• insufficient frequency of medical reviews by senior psychiatrists
• failure to escalate care following Code Black incident and expressions of suicidality
• inadequate risk assessment and documentation
• failure to convene family meetings despite repeated requests
• inadequate handover when consultant psychiatrist took leave
• poor quality observations (rounding) without therapeutic engagement
• risk rating downgraded without justification
• unsubstantiated allegations against husband limiting his involvement in care
• high ward acuity with inadequate staffing
• lack of formal clinical supervision systems
• communication failure regarding patient expressions of suicidality between advocate and nurse
• failure to document and investigate red marks on neck reported by husband

Coroner's recommendations

1. East Metropolitan Health Service should ensure sufficient funding is made available so that remediation work to address all low, medium, and high ligature risks in its mental health facilities (identified during internal and external audits) is completed as promptly as possible, as a matter of utmost urgency
2. East Metropolitan Health Service should take immediate steps to ensure that at all of its mental health facilities, clinicians assessing patients for possible admission have (at the time of that assessment) access to that patient's Mental Health Triage documentation, and any relevant outpatient notes, whether in hard copy or by way of an electronic medical record system
3. East Metropolitan Health Service should review the current system of allocating two patients to each nurse working on Ward 6 at Bentley Hospital. The review should consider whether the current allocation is appropriate in all circumstances, and whether the available mechanisms to assess patient acuity are properly able to ensure that in each case, the nurse to patient allocations are correct