41 unexpected/unnatural deaths in Australian psychiatric system in '08

February 20, 2012

AN INQUIRY into deaths in Victoria's psychiatric facilities has found serious deficiencies and has called on the Baillieu government to consider major changes to the mental health system.

The inquiry, led by Victoria's chief psychiatrist Ruth Vine, was prompted by The Saturday Age's exposure last year of the high number of people dying in mental health wards.

It has called for better staff training, improved support for grieving families and a further review every three years of violent or unnatural deaths in psychiatric units.

Dr Vine and two interstate mental health experts examined 41 unexpected or unnatural deaths in the mental health system between January 2008 and December 2008.

Their inquiry found numerous ''opportunities to further improve clinical practices and processes to provide safer treatment and care''.

Dr Vine has also called for:

■New guidelines around searching patients to prevent drugs being smuggled into mental health wards.

■A review of whether mental health providers are doing enough to stop patients absconding and are adequately suicide-proofing facilities.

■Steps to ensure ''consistent monitoring of patients overnight'' and better training around drug and alcohol issues. Her report detailed concerns from the state's mental health services that ''the current funding model for inpatient units limits the capacity of management … to manage complex patients and situations''.

Dr Vine also said an an issue ''not routinely well managed'' by health services involved ''the contact with family, carers, staff and other patients at the time of the critical incident and in the weeks or months following''.

Of the 41 deaths examined, the inquiry found that 29 most likely occurred as a result of suicide, including eight in an inpatient unit.

Thirteen of the 41 deaths occurred after a person had absconded from a unit while a further eight deaths involved patients on approved or planned leave.

Mental Health Minister Mary Wooldridge told The Saturday Age yesterday the government had accepted 12 of Dr Vine's 15 recommendations and had immediately allocated $500,000 ''to respond to urgent capital improvements'' in mental health wards.

Ms Wooldridge said she supported ''in principle'' calls for increased after-hours staffing and a review of high dependency units, but said a decision on whether they would be funded needed ''further consideration''.

''While the report shows there are a number of appropriate measures already in place to review mental health inpatient deaths, it has also highlighted that many of the issues surrounding individual deaths are common across mental health services. The government will therefore introduce a new review process to ensure there is a regular review of inpatient deaths.''

The Vine inquiry also revealed that the state coroner had, when examining the deaths of mentally ill Victorians, identified failings inside health services.

In one case, a patient had absconded from a mental health unit due to ''a combination of possible human error in leaving the rear door open, the lack of any protocol or policy to regulate access to the [unit] by non-psychiatric staff and a door that was inadequate''.

Another death involved an involuntary patient who was admitted to the inpatient unit via the emergency department but who absconded while arrangements were being made to transfer him to a high dependency unit.

The Vine inquiry reveals that the coroner found that ''anomalies'' with the way the health service had interacted with the patient were ''indicative of suboptimal care''.

A third death examined by the coroner involved a patient who had taken drugs and then hanged themselves inside a mental health facility.

Dr Vine's report states that after this death, the health service involved had identified ''a number of areas where patient management can be improved''.

The Vine inquiry also found that some health services were not ensuring adequate monitoring of patients by staff.

''In one service, night-time observations reverted to a lower level than in place during the day without this being a considered or documented decision,'' the report found.

The inquiry also noted that high dependency units for patients considered most at risk were often ''stark, with little opportunity for activities or distraction other than a television screen.

''They are not pleasant or inviting spaces. The panel was of the view that the high dependency area should not be used solely as a means of detention for those who are high risk because of their mental illness or an absconding risk.''

Source: Nick McKenzie and Richard Baker, "State's failings over deaths," The Age, February 18, 2012.