Inquest into the Death of Brian John KEALY

Contributing factors

• Fragmentation of mental health and psychological services
• Poor information sharing between PHS and PMH teams
• Disagreement about diagnosis and medication management between teams
• Inadequate senior psychiatric oversight and clinical governance
• Cessation of olanzapine without appropriate psychiatric review
• Staff shortages and excessive caseloads
• Lack of multidisciplinary team meetings
• Failure to access Dr H.'s comprehensive psychiatric assessment
• Treatment silos preventing coordinated care
• Characterization of mental health concerns as drug-seeking behaviour

Coroner's recommendations

1. Ensure Psychological Health Services (PHS) and prison mental health clinicians have reciprocal access to prisoner information stored in EcHO computer system and TOMS PHS module
2. Review delivery of mental health and psychological services at Hakea Prison; form project group with Department of Health to determine feasibility of DoH assuming responsibility for prisoner health care (including primary, psychiatric, psychological care); assess adopting multidisciplinary model of mental and psychological health care led by psychiatrist with clear clinical governance
3. Ensure all available medical, psychiatric and other reports relevant to prisoner care and treatment are freely available to treating mental health and psychological clinicians; identify and remove legislative, policy or other barriers to access
4. Ensure compliance with EMF-DIR-022 Operational debriefing policy; ensure personnel involved in critical incidents participate in immediate and formal debriefs; disseminate lessons learned reports to relevant staff including those involved in emergency response skills
5. Conduct review of mental health and psychological health clinician staffing levels at Hakea Prison to determine adequacy; redouble recruitment efforts to fill vacant positions; review salary and other benefits with view to attracting appropriately qualified clinicians