Inquest into the death of Benjamin Woodhouse

Case Number: 2020/21513

Findings Date: 26 May 2023

Magistrate: David O'Neil

CORONIAL LAW | mental health, involuntary patient, escorted leave, conditions of leave

Responses

Recommendations

North Sydney Local Health District

1. That the Local Health District (LHD) amend its leave form to be provided to the patient, family and any third-party carer to record the conditions of leave which must be complied with.

2. Where it is proposed to send an involuntary patient on leave the LHD provide a written summary to both support coordinators and care providers of a patient’s history, diagnosis, trigger points, risk, behaviour management techniques and what to do in an emergency, e.g., if the patient absconds.

Primary Care and Community Services

3. The Primary Care and Community Services (PCCS) review current management of and compliance with its risk policy and procedures in light of this case and conduct risk assessments on intake as well as when significant events occur.

4 That PCCS require a support co-ordinator to contact police and/or ambulance as soon as it is notified that a client who is an involuntary patient absconds from a carer except where such contact with police and/or ambulance has already occurred.

7. That PCCS and AFEA each develop a form based upon the NSW Police “absconded patient – report to police” form, containing relevant information to provide to the police and any other relevant agency, which sets out full information about the circumstances of the absconding.

AFEA Care Services Pty Ltd

5. That AFEA institute a risk assessment process for each client (who is an involuntary patient) which includes a regular review of such risk assessments including when relevant circumstances change.

6. That AFEA make it plain to its support workers and care co-ordinators that they are expected to contact police and/or ambulance as soon as a client who is an involuntary patient absconds from a carer.

7. That PCCS and AFEA each develop a form based upon the NSW Police “absconded patient – report to police” form, containing relevant information to provide to the police and any other relevant agency, which sets out full information about the circumstances of the absconding.

Commissioner of  Police

8. That the Commissioner of Police consider amending the absconded patient -report to police form in the light of these findings to include a requirement to specify where the patient was last seen, by whom and the contact details of the person who last saw the patient.