In December 2016, an inquest was held into the death of an aged care resident, Frederick Peisley, following a fall from stairs after Mr Peisley had displayed some suicidal, depressive and/or psychotic behaviour.


Mr Peisley sustained a brain injury in an assault in 2007 when he was approximately 53 years old. As a result, he developed a schizoaffective disorder, depression and suicidal ideations. From 2007, Mr Peisley resided in a variety of aged care facilities and had a number of psychiatric hospital admissions. In February 2012, while subject to a Community Treatment Order (CTO), Mr Peisley was admitted as an involuntary patient to the Concord Centre for Mental Health. Mr Peisley was discharged in July 2012 under a new CTO that required monthly medication and management by the Camperdown Community Mental Health Service (CCMHS). The CTO was sent to and likely received by CCMHS but was not recorded and, as a result, Mr Peisley was not managed by the service.

In August 2012, Mr Peisley was admitted to Neapen Hospital suffering a skin condition. His niece, Ms Apap, raised with staff her concern that Mr Peisley was not receiving his antipsychotic medication. Hospital staff found that Mr Peisley was displaying no psychotic symptoms and accordingly he was not treated according to his CTO.

On 15 October 2012, Mr Peisley had a mental health review which noted Ms Apap’s concerns regarding the lack of medication but it did not refer to the CTO.

Later in October, Mr Peisley was transferred to The Ritz Nursing Home, a high care and secure facility. The Ritz was not aware of Mr Peisley’s CTO prior to admission but did, eventually, receive the Concord Hospital’s discharge summary which referred to the CTO. Subsequently, a GP recommended that Mr Peisley be recommenced on anti-psychotic medication.

On 3 and 6 December 2012, The Ritz’ progress notes record behaviours that indicated Mr Peisley may have been suffering from psychosis. On 9 December, Mr Peisley was behaving erratically and attempted to leave The Ritz. At 6.00pm he was found balancing at the top of a set of stairs within the facility and half an hour later was found hanging over a stair railing. He was administered medication to reduce his agitation and moved to a room on the ground floor.

On the morning of 13 December, Mr Peisley made multiple attempts to jump off the fire escape. Close monitoring was ordered and at 3pm Mr Peisley was noted to be on suicide watch. At 6pm, Mr Peisley was reviewed by a medical practitioner and prescribed medication to reduce his impulsivity. At 6.30pm, Mr Peisley was observed to be in his room. According to an Incident Report, Mr Peisley was found at 7pm unconscious and bleeding at the bottom of the stairs. He was transferred to the Westmead Hospital, however attempts to stop the bleeding on Mr Peisley’s brain were unsuccessful and he passed away on 16 December 2012. 


The Coroner made recommendations to a number of different services involved in the care of Mr Peisley1 .

The Coroner identified that the services’ lack of awareness of Mr Peisley’s CTO was a systemic failure.

The Coroner expressed the view that at the Neapen Hospital, the medical practitioners should have made further efforts to obtain a relevant history, including the basis for the CTO, particularly before deciding not to follow the medication regime set out in it.

The Coroner accepted expert evidence that The Ritz was an appropriate facility and, had overall, given commendable care to Mr Peisley. However, the Coroner held that on 9 December, there were sufficient indications that Mr Peisley was suicidal and required medical assessment so that scheduling under the Mental Health Act 2007 or, at least, escalation to contact a general practitioner or psychiatrist could be considered.

The Coroner found that on 13 December, Mr Peisley was not subject to close monitoring, as the relevant chart was only updated hourly, not every 10-15 minutes. Further, that staff at The Ritz did not provide Mr Peisley’s full clinical picture to the attending medical practitioner because they failed to provide progress notes and adequate descriptions of Mr Peisley’s suicidal behaviours. The Coroner was also critical of The Ritz’s failure to clearly document Mr Peisley’s behaviour.


The Coroner recommended that the Ritz consider developing policies and implementing staff training with respect to identifying and managing suicidality, depression and psychosis amongst residents, and conducting a full risk assessment of all internal and external staircases.

The Coroner also made recommendations to the Ministry of Health that consideration be given to allow wider access to copies of CTOs on NSW Health Portals and to implementing training for clinicians about CTOs, particularly trainee psychiatrists.


This Inquest provides a timely reminder to both health and aged care organisations of the importance of clear and complete documentation and note taking. It also highlights the importance of educating staff regarding the possible presentations and behaviours of patients with complex mental health conditions, and of conducting a thorough risk assessment.

More broadly, this Inquest emphasises the importance of clear communication between health services, facilities and individual practitioners and the obligation to follow up references to relevant documents, such as a CTO. It was apparent in the Coroner’s findings that poor or inadequate communication of the patient’s history led to medical practitioners making decisions on incomplete information, which contributed to Mr Peisley’s untimely death.