Inquest into the death of AX

Case Number: 2020/00228990

Findings Date: 11 October 2024

Magistrate: Joan Baptie

CORONIAL LAW | death as a result of fall from height, Queen Victoria Building, acute psychotic illness, adequacy of care and treatment provided by Prince of Wales Hospital, appropriateness of police response to missing person's report

Responses

Recommendations

Director of the South Western Sydney Local Health District (SWSLHD)

1. That as a matter of priority, a review be undertaken by executive staff in relation to establishing a clear process and procedure for the mental health consumers/patients who attend the Emergency Department (ED) at Prince of Wales Hosital (POWH) but leave prior to completion of treatment, (namely, "unmanaged departures"). The review should include:

a. clarification of applicable policy for unmanaged departures, including operative 'flow charts' (such as that in Tab 35, Annexure B) and the Mental Health Clinical Nurse Consultant, Emergency Department, Prince of Wales Hospital Practice Guide (October 2023) and consideration of appropriate staff training as to such policies and procedures;

b. consideration as to implementing appropriate clinical audits of available data regarding:

i. the Mental Health Clinical Nurse Consultant "Referral Board" data;

ii. data in the form of notifications on IMS+ regarding incidents of unmanaged departure.

2. That as a matter of priority, steps be taken to ensure that mental health clinical staff in the ED of Prince of Wales have a clear understanding of the cirumstances in which consumers/patients can be scheduled under the Mental Health Act  2007 (including as to the constraints on a clinician who has not personally examined a consumer/patient).