Inquest into the Death of Sheridan Troy Hilton

Contributing factors

• Inadequate discharge planning and communication from Bentley Hospital to community mental health services
• Failure to notify referring GP and community mental health nurse of discharge at time it occurred
• Insufficient community mental health resources to provide timely follow-up
• Lack of support for family carers managing patient in community
• Non-compliance with antidepressant medication (Mirtazapine levels subtherapeutic at time of death)
• Ongoing suicidal ideation and self-harm despite psychiatric assessment
• Inadequate resourcing of Bunbury Psychiatric Unit limiting availability of voluntary patient beds
• Separation of patient from family during metropolitan facility admission
• Lack of adequate psychology services in regional mental health system

Coroner's recommendations

1. Metropolitan hospitals discharging country patients must ensure oral contact is made with community health services providing time of discharge and comprehensive management plan outline
2. Metropolitan hospitals must similarly communicate with patient's GP, especially if they were the referring doctor
3. Provide clear relevant 24-hour emergency contact information to carers upon discharge
4. Community health services must be adequately resourced to respond to discharge information and be proactive in family circumstances where warranted
5. Ensure 24-hour emergency contacts can offer realistic help and ongoing support
6. Community mental health case workers should provide assistance to the family as a whole, not just the patient, recognising that families caring for unwell members experience acute crisis
7. Where patients require assessment in facilities remote from expected carers, attempt interim care close to expected community location to enable carer interaction with treating teams and prepare carers for patient's actual progress rather than unrealistic expectations