1. From Death We Learn 2009 Absconding from a Mental Health Unit Office of Safety and Quality in Healthcare Reference: Slater Inquest July 2008

2. Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together Office of Safety and Quality in Healthcare The case Background A woman in her 20’s was admitted as an involuntary patient to a tertiary psychiatry department Presented with psychotic symptoms: grandiose & religious delusional beliefs extensive history of drug induced psychosis with mixed affective features associated with amphetamine & cannabis abuse injected morphine the night before presentation prior history of absconding from the mental health unit

3. Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together Office of Safety and Quality in Healthcare The case Management During the admission: The patient had persistent psychotic symptoms The patient’s usual methadone dose was initially given but subsequently withheld due to over-sedation

4. Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together Office of Safety and Quality in Healthcare The case A week after admission the patient absconded from hospital On the day the patient absconded: –The patient did not sleep, was teary & complaining of physical symptoms which she attributed to methadone withdrawal –The patient settled & was allowed nurse escorted ground access  during which time she fled hospital –The hospital notified the police –patient was listed by the hospital as absent without leave

5. Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together Office of Safety and Quality in Healthcare The case Outcome The patient was:  not located  discharged after 3 days when she did not return  found deceased 3 days after she left hospital

6. Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together Office of Safety and Quality in Healthcare The inquest A coronial inquest revealed: The patient died of a ligature injury to the neck (hanging) with no other signs of injury. The patient had taken morphine, codeine, amphetamines and cannabis after absconding form hospital. The nurse escorting the patient was not aware of the patient’s past history of absconding from the mental health unit. Police efforts to locate the patient were limited. Despite being absent without leave for 3 days, the deceased continued to be an involuntary patient pursuant to the terms of the Mental Health Act. The State Coroner noted that Section 52 of the Mental Health Act only enables a psychiatrist to order that a person who is “detained” no longer be an involuntary patient.

7. Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together Office of Safety and Quality in Healthcare The inquest The State Coroner recommended: Hospitals in Western Australia providing mental health services should ensure that their files, both paper and electronic, contain an alert section which records occasions on which an involuntary patient has absconded from hospital and the context in which the absconding took place The mental health services policies and procedures manual relating to missing or suspected missing patients be amended

8. Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together Office of Safety and Quality in Healthcare Key messages  Mental Health Services should utilise alerts for identifying patient’s prior history of absconding from mental health care.  An order for release of an involuntary patient can only be made by a psychiatrist whilst the patient is detained and does not apply to a person who is absent without leave.  Illicit substance use can have harmful effects on the mental health of a patient.  Management of substance withdrawal is important in patient care.