Flawed leave procedures contribute to a patient’s death

A coronial inquest has found a lack of formal procedures around leave from a mental health unit contributed to a patient taking his own life.

The patient, a regular cannabis user, started experiencing mental health issues and attempted suicide two months before he was admitted to a public hospital mental health unit.

The patient first came to the attention of mental health services after experiencing visual and auditory hallucinations. A family member called the police, and he was involuntarily admitted to the mental health ward.

On the ward, he was floridly psychotic and combative, and it was thought he was experiencing a drug-induced psychosis.

The patient was initially placed in a high dependency unit to receive treatment. Two days later, he was transferred to an open ward and commenced on the injectable anti-psychotic medication aripiprazole 400mg.

Despite still experiencing delusions, he was discharged nine days later, prescribed an additional oral anti-psychotic to be taken daily and referred for community follow-up.

While back home with his family, the patient attempted to take his own life and continued to experience delusional beliefs. He was involuntarily admitted and two days later, he made a third suicide attempt.

According to an expert witness, it was likely he had stopped taking his oral anti-psychotic medication and resumed cannabis or other substance use after he was first discharged from the mental health unit. The expert said, “this combination would have ignited the more malignant symptoms of his psychosis.”

Escorted leave approved

Ten days after being admitted for the second time, the patient denied thoughts of self-harm but remained psychotic, so his medication was switched to zuclopenthixol.

He was given his first dose of zuclopenthixol and approved for escorted leave by the psychiatric registrar. He spent half an hour with his family away from the hospital.

The following day he went on escorted leave again from 3.30pm and was due to return at 8.00pm. He drove himself to a relative’s house, where he was told another relative had died. After expressing his sympathy, he returned to his family home.

Tragically, early that evening, he took his own life.

Leave of absence laws

Granting a leave of absence for a patient from a mental health unit must be approved by an authorised person, usually a psychiatrist, in accordance with the relevant state or territory legislation.

In this case, the relevant legislation was the Northern Territory Mental Health and Related Services Act 1998 which clearly outlines the requirements for granting leave for involuntary patients. A patient can leave the hospital for certain periods if these three pre-conditions are fulfilled:

1. leave is granted in accordance with approved procedures
2. leave must be recorded in the approved form
3. leave is subject to the conditions determined by the authorised psychiatrist.

Multiple failings

The inquest highlighted that the ward staff and mental health service failed to uphold all three pre-condition requirements and to identify and mitigate risks to the patient.

The coroner found that at the time the patient was granted leave there was no approved procedure for involuntary patients in place. There was also a lack of training for granting leave and staff held differing views on the requirements. The psychiatric registrar said his knowledge came from “on the job training” and if he was asked to complete the approval form, it was given to him by the nurses.

The coroner also identified flaws with the hospital’s leave form. It was signed by the psychiatric registrar, but not by the primary carer/responsible adult (as required on the form) and no conditions were stipulated as there was no designated space on the form.

The consultant believed the approved leave was for one day, and the patient would be reviewed before leave was approved again. However, the registrar noted on the approval form that the patient could leave ‘daily until 8pm’ and believed there was no need for another form.

The coroner found the patient was not reviewed by the consultant or the registrar on the day he left the ward and took his own life. The coroner also noted that during the two weeks he was in the mental health ward his psychosis was still present, and he remained at risk of harm to himself and others.

Finally, the coroner highlighted the patient’s family were not fully aware of his illness, treatment, and the risks he posed. They were not provided education or advice in monitoring, observing, and supervising him outside of the hospital.

Coroner’s recommendations

Ultimately, in relation to granting leave, the coroner noted there was lack of appreciation of the risks and appropriate mitigation due to inadequate procedures and training.

The mental health service’s clinical director acknowledged the inadequate risk assessment of the patient and the staff’s failure to recognise his protracted psychotic condition as an ongoing risk. The director confirmed an approved procedure for granting leave had been implemented as a result of his death.

The coroner recommended the mental health service ensure its procedure and form supported the appropriate patient risk assessment before leave was granted. In addition, the form should have sufficient space for conditions to be legibly written and appropriate information for the patient's family/carer on what to do and who to contact if things go wrong.

Key lessons

In this case, the coroner was critical of the mental health service and the lack of procedures and training for staff on approving leave of absences. However, psychiatrists need to be aware of their responsibilities when approving leave. Requirements will differ in each state or territory, and each hospital will have a procedure. Ensure you are aware of and follow the requirements that apply in your institution and in the jurisdiction in which you practise.

A communication breakdown can have serious ramifications, so it’s important you clearly and consistently communicate with the family or primary carer (subject to privacy and mental health laws), so they understand the severity of the patient's mental illness and any risks they may pose to themselves or others.

A thorough risk assessment needs to be completed when considering a leave of absence, and psychiatrists and their registrars are on the same page about the plan, amount of leave and time of the next patient review.