Coroner finds flaws in Fremantle Hospital psychiatric unit

AN inquest into the deaths of five people at a Perth psychiatric unit has found poor communication and procedures meant carers were not properly consulted when patients were admitted and discharged.

The WA Coroner’s Court examined the deaths of Stephen Colin Robson, 47, Ruby Natasha Nicholls-Diver, 18, Michael Ronald Thomas, 57, Anthony Ian Edwards, 26, and Carly Jean Elliott, 20.

All had attended the Alma Street Centre at Fremantle Hospital between March 2011 and March 2012, and took their own lives.

Two patients died within a day of being discharged, one was an involuntary patient who absconded and died the same day, one disappeared within a day of being discharged and was later found dead, and one died a month after her last contact with the unit.

In findings made public on Friday, state Coroner Ros Fogliani said the communication standards were below expectations, but clinicians were not uncaring, deliberately dismissive or disrespectful.

She also noted there had since been improvements in communication with families.

Ms Fogliani found there were no formal policies that required staff to involve a patient’s carer in the planning of their admission or discharge, though it was considered best practice.

She also found there were inadequate procedures at the time for taking into account a patient’s longitudinal risk factors.

But the coroner said that had changed with the establishment last year of the Assessment and Treatment Team, which managed patients for up to 12 weeks and could refer a person to outpatient care.

Ms Fogliani commented that carers could provide relevant information to clinicians.

“(But they) were left with insufficient understanding of their loved one’s diagnosed condition, their medication regime, the factors that may indicate there is a risk of relapse and when to re-engage with the mental health system,” she said.

Ms Fogliani recommended the Health Department develop carer plans and the State Government continue to progress recommendations from Bryant Stokes’ 2012 review of the mental health system, which suggested ways to prevent similar deaths.

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