Inquest into deaths of Alma Street psychiatric clinic patients cites poor communication
By Emily PiesseA coronial inquest into the deaths of five patients linked to Fremantle Hospital's psychiatric unit has found poor communication and procedures meant carers were not adequately consulted by staff when patients were admitted or discharged.
The inquest was called after five patients from Alma Street Clinic took their own lives between 2011 and 2012.
A coronial inquiry into the deaths ran for almost three weeks in 2015.
The report was handed down today.
State coroner Ros Fogliani found communication at the clinic was below the standard expected of a professional mental health service at the time.
She said policies governing contact between staff and carers during patient admissions were inadequate, as were procedures for clinicians to consider patient risk factors.
... on occasion, vital information concerning the patient, which could have been provided by the carer, was missed.
Consequently, on occasion, clinical judgements were made in the absence of relevant information.
"The planning around improvements in the delivery of mental health services will need to translate into action. The seriousness of the problem cannot be underestimated," she found.
"...on occasion, vital information concerning the patient, which could have been provided by the carer, was missed.
"Consequently, on occasion, clinical judgements were made in the absence of relevant information."
The coroner found that "some of the mental health clinicians were overworked, and there were lapses in care."
In addition, "the engagement with the carers was of secondary importance."
Ms Fogliani has recommended the Health Department develop carer plans to address consent and risk issues.
She also said the State Government should continue to progress the recommendations of the Stokes Review.
Professor Bryant Stokes completed an independent review of the mental health system in 2012, recommending strategies to prevent similar deaths.
Father not surprised by findings
Geoff Diver, whose daughter Ruby Nicholls-Diver died in March 2011 after being discharged from the Alma Street Centre, said the coroner's findings were not surprising.
"I'd always bemoaned the lack of communication [with clinic staff] but the evidence supplied was basically there was no excuse for it," Mr Diver said.
"It not only vindicates that these events led to Ruby's death, but it actually goes further than I ever have done publicly."
Ms Fogliani said Alma Street staff made no attempt to contact Mr Diver and his concerns about his daughter were not passed on to her medical team.
In addition, no records were kept of Mr Diver's repeated attempts to contact staff.
Ms Fogliani also found the psychiatrist treating Ms Nicholls-Diver did not exercise sound clinical judgement during her discharge.
"The worst thing for me was in the inquest, the psychiatrist said he had no grounds to make Ruby an involuntary patient, and I feel sure that if he had have spoken to me with my knowledge and history with Ruby, her risk would have been elevated to the point where … she could have been made an involuntary patient," Mr Diver said.
Health service has learnt lessons: Minister
Health Minister Helen Morton said the coroner's report had highlighted that services at the clinic were not at their best.
"The rest of the state's mental health services have learnt from those tragic experiences and people with a mental illness are getting a much better outcome, in terms of service delivery, than they ever have before," she said.
She said she was confident that new legislation, implemented in November 2015, had already done much to deal with many of the recommendations from the coronial inquiry.
Ms Morton said 61 per cent of the coroner's recommendations had been implemented, and the rest would be.