Coroner Audrey Jamieson recently delivered her findings in relation to the death of a patient who committed suicide after absconding from the emergency department (ED) of a hospital.1

The patient had a history of mental illness and had voluntarily presented himself to the ED concerned.  It was determined he should be admitted to the psychiatric ward, however, as no beds were available at the hospital or in the region, the patient was admitted to the ED until a bed in the psychiatric ward became available.  Whilst admitted to the ED, the man absconded and committed suicide on 30 July 2008 (the 2008 incident).

Whilst the initial procedures and development of the patient’s management plan were appropriate in the circumstances, the Coroner determined that, from that stage onwards the care became inadequate.  The findings focus specifically on the lack of adequate clinical handover within the ED.

Involuntary v voluntary admission

As the patient voluntarily admitted himself to the hospital, he was not provided with the supervision and protection of an involuntary admission. This was despite the fact that if he attempted to leave the ED, the Mental Health Act 1986 (Vic) could be invoked to admit him as an involuntary patient.

The patient had a history of absconding, having left the ED without receiving treatment on 21 out of 25 presentations, including six occasions in the month prior.  The management plan designed for the patient specifically recognised the risk of absconding and that supervision would be required.  It appears however that there was no discussion between the psychiatric and emergency departments as to the precise level of supervision required, and an earlier disappearance by the patient within the hospital was not reported through the correct channels.


The Coroner placed considerable emphasis upon the procedures in place at the time of the incident and the developments to the hospital’s procedures since the 2008 incident.

The Coroner noted that it is now common place to use a Constant Patient Observer (CPO) if a patient is an absconding risk, however, that proper procedures for the CPO need to be developed to ensure the role is properly utilised and effective. The Coroner also questioned the evidence of a witness who believed a CPO was not necessary where a patient presented as a voluntary admission.

Emergency Department admission as a temporary measure

The Coroner recognised that it was unclear whether the ED was the most appropriate place for the patient whilst acknowledging that that there may have been no available alternative.

The Coroner found that an assumption had been made that the ED provided the same level of safety as an inpatient mental health unit and that despite the fact the care plan was appropriate, the measures in place to implement it were unlikely to function in an ED environment.

The Coroner noted that it did not appear that a handover of responsibility from the psychiatric team to the ED occurred, and, as a result, the system in place broke down. In order to avoid the failure of such systems, responsibility should have been clearly allocated to a single party and maintained by that party.

Record management

The Coroner’s findings indicated that although there were a number of documents containing information to assist staff in use, these documents were not file specific.  They did not transfer with the patient’s file and were not necessarily available to the relevant people at the relevant time to ensure that the correct care and supervision was provided.

Although recognised by the Coroner as ‘trite to say’, a comprehensive clinical handover should occur in every instance relating to patient care to ensure the basic tenets of primary health care are provided.


A hospital will be judged by the records maintained and the procedures in place.  Where an incident has occurred, a hospital will more readily establish that appropriate action was taken where adequate procedures are in place and the hospital can indicate it has turned its mind to the specific protection required.  In the current case the procedures and safeguards in place were found to be inadequate.

As important as procedures are, the Coroner clearly identified the importance of tailoring the care provided to the individual circumstances.  In the present case it is clear that the patient’s history of absconding and recognised suicidal tendencies, were not adequately addressed and the consequences of not doing so were significant.

Voluntary mental health patients pose inherent difficulties in balancing the individual’s right to independence and autonomy, with their right to receive a standard of care that facilitates appropriate caution.  Voluntary patients at risk of absconding will continue to present difficult management issues when adequate facilities cannot be immediately provided.  As such, hospitals should take considerable care to ensure patients do not fall through the gaps.