Inquest into the death of Stephen James Douglas

Case Number: 2019/00376134

Date of Findings: 8 August 2025

Magistrate: Deputy State Coroner, Kasey Pearce

CORONIAL LAW – mental health-homicide-community mental health treatment – mental health policy and practice

Responses

Recommendations

To the Chief Executive Officer, Sydney Local Health District (SLHD)

1. The SLHD review its Mental Health Shared Care documentation (Plan, Checklist and GP Information Sheet), with a view to: 
   • better defining the roles and responsibilities of the GP or medical practice and the Mental Health Service under the Mental Health Shared Care Plan, including (but not limited to) specifically: 
     • the frequency of periodic psychiatric review of a patient by the Mental Health Service; and 
     • the frequency of periodic clinical review meetings between the GP or medical practice and the Mental Health Service; and 
     • arrangements for in the event of the absence of either the allocated GP or allocated Mental Health Service staff member. 
   • better defining the expectations of communication between the GP or medical practice and the Mental Health Service under the Mental Health Shared Care Plan; 
   • encouraging GPs to contact HealthPathways to assist them in assessing and managing any deterioration in the mental health of Mental Health Shared Care Plan patients and determining who to contact in the event of deterioration; 
   • including information as to who at the Mental Health Service can be contacted by the GP/medical practice in the event of concern about deterioration in the patient’s mental health 
2. The SLHD formally implement a requirement that all SLHD Community Mental Health Service clients be scheduled for review by a psychiatrist, at a minimum within three months of the expiry of any Community Treatment Order and again within a further three months.
3. The SLHD consider as part of its ongoing electronic record systems changes, the creation of a flag, or other alert, identifying the due date for all Community Mental Health Service clients’ periodic psychiatric reviews, which is identifiable both in the client’s individual records and in summary reports used for the purpose of staff caseload review and management. 
4. The SLHD amend its Core Team Model of Care guideline to provide: 
   • the maximum care load for care coordinators is 30 clients; and 
   • the trigger for a clinician and manager to review a care coordinator’s care load is 25 clients.
5. The SLHD take steps to maintain within all Community Mental Health Service Core Teams, for all hours of operation, rostering of at least two “accredited persons” (in addition to psychiatrist capacity) able to schedule clients under the NSW Mental Health Act 2007.
6. The SLHD review its Acute Care Service and Core Team policies and procedures to clearly define and communicate to staff in both teams in what circumstances, and how, transfer of care of Core Team clients in need of Acute Care Service care is to occur, and to simply the process by which such a transfer takes place.
7. The SLHD review MH_SLHD_PCP2024_006 Working in the Community-Community and Home Visiting to: 
   • more clearly communicate the requirements that: 
     • community or home visits to clients may not be conducted by a single staff member: 
       • for the first visit to the client’s home or new home, including where the client is re-commencing with the service; 
       • where there is evidence of, or concerns about, a client’s mental health deteriorating, regardless of any existing approval for visits to be conducted by a single staff member;
       • where there is a risk of violence, or the risk of violence is unknown;
     • all unplanned home or community visits which arise for consideration after the morning Community and Home Visit Huddle must be the subject of discussion with and approval by the Team Leader, or if the Team Leader is unavailable, an alternative senior clinician who is authorised to approve such visits.
     • where after the morning Community and Home Visit Huddle or subsequent discussion and approval, but prior to the conduct of the visit, further information is received that may alter the assessment of risk about the conduct of the visit, the decision to undertake the home visit must be the subject of further discussion and approval by the Team Leader, or if the Team Leader is unavailable an alternative senior clinician who is authorised to approve such visits. 
   • include cross-reference to the SLHD’s Mental Health Service Policy Directive MH_SLHD_PD2023_027 Consumers with Mental and/or Cognitive Acute Deterioration - A risk assessment and management approach and any other internal resources on client mental state deterioration; and ensure clarity and consistency in its use of the term ‘Huddle.’
8. The SLHD review the Community and Home Visit Huddle procedure to: 
   • require the discussion of a dynamic assessment of the safety risk to staff involved in the conduct of a home or community visit that day (whether consideration of the visit occurs at a daily Huddle meeting or otherwise); 
   • require the recording of a “decision” with respect to whether or not and how a home or community visit will be undertaken that day (whether that decision is made during a daily Huddle meeting or otherwise); and
   • include a re-statement of the policy position as to when home and community visits may not be undertaken. 
9. The SLHD formally implement a requirement that all Community and Home Visit Huddles must be attended by the relevant Team Leader and, [when reasonably possible], a psychiatrist.
10. The SLHD formally implement a requirement that all new Community Mental Health Service staff members must not undertake any home or community visits to clients alone in the first 3 months of employment.
11. The SLHD review its workplace health and safety policies, procedures and practices to consider whether the scope of the daily Community and Home Visit Huddle should be formally expanded to include discussion about safety issues generally for the relevant team that day, not merely safety issues concerning visits to clients in homes and elsewhere in the community.
12. The SLHD review the Core Team Model of Care with a view to including direction on handover planning for periods of staff leave.

To NSW Health

1. NSW Health consider implementation of these recommendations in Community Mental Health Services state-wide.