Inquest into the death of GP

Findings and Recommendations

Findings and Recommendations of the Inquest

Case Number: 2023/265561

Date of Findings: 31 March 2025

Magistrate: Deputy State Coroner, David O'Neil

CORONIAL LAW – mental health, abscondment from mental health facility, hospital care and treatment, police response to abscondment, ADHD, Vyvanse,  manner of death

Responses

Recommendations

To Northern Sydney Local Health District:

1. That it consider introducing a consistent form for use in all of the local health districts (LHD) mental health units and Psychiatric Emergency Care Centres (PECC), for staff to record a patient’s belongings, including mobile phones and the location of those belongings.

2. That it provide further training and guidance to mental health service staff on the use of property forms in mental health units and PECCs, to ensure these are completed consistently and how they may be referred to in the event that a patient absconds.

To the Commissioner of Police and NSW Health

3. That they consider amending the absconding patient form when it is published with the next version of the Memorandum of Understanding, or sooner if practicable, to include a question “Does the patient have access to a mobile phone or other electronic device?” (with options YES, NO, UNCERTAIN) together with the mobile phone number.