Inquest into the death of S B

Case Number: 2017/85386

Date of Findings: 16 September 2022

Magistrate: Deputy State Coroner, Magistrate Derek Lee

Catchwords: CORONIAL LAW – self-inflicted death of involuntary patient, Kaoriki House, clinical documentation, neuropsychiatric assessment, forensic assessment, risk assessment, observation levels, Mental Health Act 2007, Mental Health and Cognitive Impairment Forensic Provisions Act 2020, medication regime, use of interpreters discharge planning, environmental hazards, structural vulnerability points

Responses

Recommendations

To the Chief Executive, Hunter New England Local Health District:

1. I recommend that consideration be given to amending the Mental Health: Assessment and Management of Mental Health Patients on section 19(b) of the Mental Health and Cognitive Impairment Forensic Provisions Act 2020 Clinical Guideline so that it explicitly instructs staff at declared mental health facilities, upon a patient’s presentation to a facility pursuant to a section 19(b) order, to make a referral to Court Liaison Services for the purpose of facilitating provision of information regarding a patient’s legal proceedings from court registries.