Inquest into the Death of Radinka MIHAJLOVIC
Delivered on :5 January 2017
Delivered at : Perth
Finding of : Deputy State Coroner
Recommendation No. 1
Patients with mental health issues which require treatment in either the public or private health system be provided with a community liaison person (coordinator) who understands the treatment/management plan in place for that patient and is in a position to ensure proper coordination of the patient’s care between all relevant facilities and practitioners.
Recommendation No. 2
Discharge planning from a facility, or referral from one mental health practitioner to another, always include the nominated community liaison person, in person, at any conference when the deceased and their community carers are present to ensure understanding and continuity of management for the patient.
Recommendation No. 3
The issue of patient confidentiality not to include the fact of treatment and management as between a community liaison person and other mental health practitioners, only the content of private disclosures.
Orders/Rules : N/A
Suppression Order : N/A
Summary : At the time of the deceased’s death, the deceased had been placed on a Community Treatment Order under the Mental Health Act 1996 to be supervised by a Consultant Psychiatrist at Inner City Community Mental Health Service. The Community Treatment Order was in place for three months and due to expire on 21 June 2012.
The deceased had been residing in Western Australia since 1999 and suffered from bipolar affective disorder and post-traumatic stress disorder. One of the manifestations of the deceased’s mental health issues was her belief her treatment was making her physical unwell. The deceased’s care was managed through both the public and private mental health systems. Unfortunately the deceased’s concern with confidentiality restricted full and appropriate communication between the public system and her private practitioners.
It was considered appropriate the deceased be treated by way of depot medication, to avoid her requiring daily oral medication. She was provided while an inpatient with depot olanzapine on 6 March 2012 with the expectation she would be provided with her next depot injection on 20 March 2012 in the community. Unfortunately, there was no effective discharge planning for the deceased and there was a misunderstanding about the medication to be used. The deceased did not receive her ongoing depot, nor could she be compelled without consent.
On 21 March 2012 the deceased was assessed as needing medication and was placed on a Community Treatment Order to ensure her compliance with medication. Risperidone was considered the appropriate medication, however, she was not provided with any form of medication pending a scheduled review by her supervising psychiatrist on 30 April 2012. The deceased was reviewed earlier than the scheduled review by her supervising psychiatrist and provided with oral risperidone on 4 April 2012. This was not effective and she was given her first depot risperidone on 30 April 2012. She was extremely distressed the next morning and conveyed a strong wish to die to her private psychiatrist. The events of the rest of 1 May 2012 reflect a serious disjunction in communication between the public and private mental health systems, which culminated in the deceased’s suicide later in the afternoon.
The Deputy State Coroner’s recommendations have been directed towards focusing on appropriate community care plans with an understanding of all aspects of a patient’s care and on ability to coordinate an appropriate plan in the community which would accommodate the need for admissions and continuing care from time to time.
The Deputy State Coroner found the deceased died on 1 may 2012 on the train tracks at Maylands Train Station, Maylands as a result of multiple injuries and death occurred by way of suicide.
Catch Words : Community Treatment Order : Patients who are non-compliant : Communication : Continuity of management of patients in the mental health system : Patient confidentiality : Suicide
Last updated: 15-Feb-2017
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