Inquest into the death of Roger Schnelle

Case Number: 2021/122654

Date of Findings: 16 May 2024

Magistrate: Erin Kennedy

CORONIAL LAW | diagnosis of mental health condition; psychotic depression / depression with psychotic features; care and treatment provided during admission at Nolan House including adequacy of risk assessments, observations, and treatment plans; method and nature of self-harm; impact of Nolan House being subject to both NSW and Victorian health oversight, policy, and guidelines; need for implementation of an electronic medical record across Albury Wodonga Health mental health services; need for induction process for locum and visiting staff members; need for implementation of improved risk assessment tools

Responses

Recommendations

Chief Executive Officer Albury Wodonga Health

1. That consideration be given to continuing to advocate with NSW Health and the Department of Health, Victoria, for the implementation of an electronic medical record across Albury Wodonga Health mental health services. Such a record should ideally be compatible with systems in both NSW and Victoria, and should include standardised documents for the assessment, formulation and management of risk and patient observations.

2. That consideration be given to a review being undertaken of the Albury Wodonga Health mental health service policy relevant to risk assessment, patient observation and documentation to ensure compatibility with both NSW and Victorian policies. Where those policies are not compatible, draw this to the attention of NSW Health and the Department of Health, Victoria, in accordance with the process described in the AWH Memorandum of Understanding.

3. That consideration be given to implementing Risk Assessment Tools that focus on assessment, formulation, and importantly management of risk and consider risk indicator factors that are associated with an increased suicide or suicidal behaviour, as set out in the expert evidence of Dr Eagle.

4. That consideration be given to ensuring that the induction processes for locum and visiting staff members clearly identify relevant policy and practices in relation to the assessment, formulation and management of risk documentation and patient observations.