Inquest into the death of Houston PEEL

Contributing factors

• significant delay in emergency department assessment (9-hour wait)
• failure to implement Did Not Wait policy requiring follow-up
• incomplete collateral history from family not conveyed to clinical staff
• patient left unaccompanied to ED without family support
• inadequate reassessment when patient found wandering confused at 7:30 am
• patient left ED without medical or psychiatric review despite 4+ hour wait
• operational inability of ED to enforce its own policies due to overcrowding
• systemic ED overcrowding and lack of mental health crisis capacity
• prescription of antipsychotic without prior medical assessment

Coroner's recommendations

1. SMHS should examine ways to improve treatment of mental health patients in ED by: providing therapeutically appropriate waiting area; employing mental health clinicians and peer workers in ED waiting room; developing streamlined process for mental health patients to be reviewed by mental health clinicians earlier; considering whether alternative care models (e.g. South Australia's Urgent Mental Health Care Centre) could be offered
2. SMHS should review appropriateness of prescribing psychotropic medications to ED mental health patients without prior medical review by a doctor
3. SMHS should improve policy dissemination system by filtering or curating policy lists, and consult with junior and senior medical, nursing and allied health staff to develop streamlined system ensuring staff awareness of applicable policies