Coroner's Court of Western Australia

Inquest into the Death of Paul STRANGE

Inquest into the Death of Paul STRANGE

Delivered on :27 September 2019

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations :Yes

Recommendation No. 1
EMHS consider amending its Care Coordination in Mental Health policy to include a requirement that prior to discharge, mental health consumers are handed a card showing the date and time of all of the appointments that have been arranged with the services they have been referred to.

Recommendation No. 2
EMHS consider amending its Care Coordination in Mental Health policy to include a requirement that all discharge summaries issued to mental health consumers must contain: contact details of emergency services; out of hours contact numbers and other support services including the Mental Health Emergency Response Line; details of the appointments made with any service or agency the patient is being referred to (this is in addition to, not in lieu of the appointment card referred to in Recommendation 1); information on the process of re-entry to EMHS (or other relevant health service) if needed; and the name of the mental health consumer’s clinician or care coordinator.

Recommendation No. 3
EMHS consider amending its discharge procedure so that, except in exceptional circumstances, it is not possible to either print off a mental health consumer’s discharge summary, or to discharge that consumer until appointments have been made and an appropriate handover of information has occurred, with all of the services that the consumer is being referred to on discharge.

Recommendation No. 4
EMHS consider developing strategies to ensure that clinical and non-clinical staff are familiar with key policies. Those strategies might include handing new staff a list of the top 10 policies they should be aware of and discussing key policies (including any changes) at regular team meetings.

Recommendation No. 5
EMHS examine the feasibility of establishing a post discharge follow-up team, especially with respect to ‘out of area’ admissions, to bridge the gap between the point when a mental health consumer is discharged from an EMHS inpatient service and the point when that consumer is accepted by the receiving service.

Recommendation No. 6
The Office of the Chief Psychiatrist consider issuing guidelines as to what communications can be had with a mental health consumer’s family or support person in circumstances where a competent and voluntary consumer refuses to have their family or support person involved in their care. Consideration should also be given to issuing an abridged version of any guidelines that are published, as a practice note. 

 Orders/Rules : N/A

Suppression Order : N/A

Summary: The deceased died at Joondalup Health Campus on 9 December 2016 as a result of ligature compression of the neck. He was 30 years of age.

An inquest was held into the deceased’s death on 4-6 September 2019. The inquest focused on the deceased’s treatment and care while he was an inpatient, his discharge arrangements and the circumstances of his death.

The deceased’s was diagnosed with chronic major depression with anxiety and personality vulnerabilities. His condition was characterised by repeated incidents of self-harm, usually involving the deceased placing ligatures over his neck or stabbing himself in the hand with plastic cutlery.

On 8 April 2011, the deceased was seen at the ECU Student Counselling Service. He told a counsellor he was not managing stress well and was having trouble eating and sleeping. He discussed past suicidal ideation relation to the breakdown of a three-year relationship and his discharge from the Australian Army. In 2014, the deceased was an inpatient on two occasions at Joondalup Mental Health Unit.

In November 2016 the deceased was referred by a GP to the Joondalup Health Campus (JHC) after he presented with symptoms of depression with suicidal ideation, intent and plan, and multiple self-harm and suicidal attempts over the preceding few days. Because of the unavailability of beds at JHC, the deceased was transferred to Royal Perth Hospital (RPH) and admitted as a voluntary patient. While at RPH his medications were adjusted and rationalised, he participated in group sessions, had psychological therapy and input from a social worker and an occupational therapist. On 15 November 2016, the deceased attempted to asphyxiate himself by wrapping a blanket around his neck. While the deceased was in hospital, his family visited him regularly and took him out of hospital on leave. The deceased was discharged into the care of his parents on 28 November 2016 without any follow-up from a community mental health service having first been arranged.

On 9 December 2016, the deceased’s sister had a conversation with him about some recent work experience he had completed. She thought he seemed well. She left the deceased at her parent’s place and returned two hours later to find the deceased on the back patio, with an electrical extension cord around his neck, hanging from a suspended bicycle. A neighbour assisted with CPR and emergency services were called. Ambulance officers arrived and took over resuscitation efforts before transporting the deceased to JHC. Despite the efforts of the neighbour, ambulance officers and hospital staff, the deceased could not revived.

The Coroner found a number of aspects of the deceased’s treatment and care were unacceptable, including inadequate note taking, the failure of staff to revisit the deceased’s reported reluctance to have his family involved in his care and his discharge plan. The coroner concluded that when viewed globally, the deceased’s care at RPH was suboptimal.

In light of his observations about the deceased’s care at RPH, the Coroner made six recommendations.

Catch Words : Inpatient Note Taking : Discharge Plans : Involvement of Family Members : Hospital Policies : Guidelines for Communication : Ligature Compression of the Neck : Suicide.


Last updated: 14-Nov-2019

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