Inquest into the death of Carley Metcalfe

Case Number: 2017/362424

Date of Findings: 25 February 2022

Magistrate: Deputy State Coroner, Magistrate Teresa O'Sullivan

Catchwords: CORONIAL LAW – cause of death; search for missing person in Mullumbimby; adequacy of police investigation; Missing Persons Standard Operating Procedures; care and treatment at Lismore Base Hospital; mental health diagnosis; discharge planning and procedure.

Responses

Recommendations

To the Commissioner of the NSW Police Force:

1. That the Missing Persons Registry (MPR) consider amending the definition of “missing person” in the Missing Persons Standard Operating Procedures (MP SOPs) to make it clear that no particular form of words need be used by an informant when reporting a missing person. If it is communicated to police that a person cannot be located and there are concerns for their safety and welfare, that person is a missing person.
2. That the MPR consider amending the MP SOPs to:
   (a) Require that police attempt to identify, and obtain and safely store the last known CCTV footage of a missing person as a matter of course within the first 48 hours of a missing persons investigation.
   (b) Make clear that CCTV footage is a valuable resource in a missing persons investigation, even if its forensic significance is not immediately apparent and/or there may not be human resources to view the footage immediately.
   (c) Include “identify any obtain any potentially relevant CCTV footage” in the mandatory maximum investigation timeframes for the Officer in Charge of an investigation, ideally within 48 hours. 

To the Northern NSW Local Health District (NNSWLHD):

1.  That the Northern NSW Local Health District (NNSW LHD) ensure that the summary document page on HealtheNet includes information that easily identifies a mental health patient’s past admissions, any psychiatric diagnoses, any mental health-related incidents (including incidents of violence, or self-harm/suicide attempts), and any other relevant information that may be significant for an assessing clinician to know when undertaking an assessment within the Emergency Department or elsewhere. 
2. That the NNSW LHD consider expanding the scanning project within NNSW LHD to cover all hospitals and medical centres in the LHD, so that paper records for mental health patients so that they are available as part of the Electronic Medical Records System.
3. That the NNSW LHD:
   (a) formalise, whether by way of a written procedure or similar, the practice of inpatient mental health units and community mental health services obtaining medical records and any assessment reports from the Justice Health and Forensic Mental Health Network and where appropriate, from any other available source (including a court or legal practitioner) in circumstances where a consumer/patient has been psychiatrically assessed whilst in custody, and the medical records and assessment reports are likely to be of clinical relevance; and
   (b) take measures to press for those records to be scanned or otherwise made easily available electronically to clinicians.
4. That the NNSW LHD introduce the use of instant salivabased testing for the detection of illicit drug use by mental health clinicians within NNSW LHD emergency departments and elsewhere as required.
5. That the NNSW LHD assess and determine the need for a Psychiatric Emergency Care Centre at Lismore Base Hospital.