Mitchell Follent died on 20 August 2016 from severe head injuries, after deliberately falling head first from a third floor balcony. Autopsy examination indicated the presence of antidepressant, anticonvulsant and antipsychotic medications, in addition to cannabinoids.
Mitchell had been recently discharged from the Ipswich Mental Health Unit on 15 August 2016, after a ten-day admission following referral by his GP for investigation of possible 'psychosis'. It was identified in the Root Cause Analysis Report that Mitchell was discharged from the Ipswich Mental Health Unit in the absence of sufficient support, and that discharge of a patient with high and complex needs should be managed through a meeting of all stakeholders in the patient's care.
Background Facts
Mitchell Follent was admitted to the Ipswich Hospital Mental Health Unit ('MHU') on 5 August 2016, following a referral by his GP for investigation of possible 'psychosis'. It was his first mental health admission, yet Mitchell had a history of acquired brain injury, epilepsy / seizures and cannabis use. Earlier in the year on 23 July 2016, Mitchell was brought by ambulance to the Ipswich Hospital emergency department for grand mal epilepsy. He discharged himself against the recommendation of emergency department staff.
Recent behaviour prompted the admission to the MHU on 5 August 2016, where Mitchell's mother had noticed a deterioration in his ability to self-care and unusual behaviours, including Mitchell talking to himself and laughing at inappropriate times. The MHU assessed Mitchell as having 'likely drug-related / post-ictal psychosis'. An Involuntary Treatment Order was made. Security escorted Mitchell to the MHU and the medications diazepam, olanzapine and lorazepam were prescribed.
Mitchell failed to settle at the MHU, as he continued to enter the rooms of other patients. Consequently, security was again required to restrain Mitchell. During this period, Mitchell fell unwitnessed, resulting in a 2cm laceration to his nose.
A review was conducted by the on-call consultant psychiatrist at 6.00pm, where the impression of complex partial epilepsy was formed. It was planned for Mitchell to continue with his anticonvulsant and antidepressant medications, with neurological observations every two hours. Nothing additional was noted after further assessment the following morning.
On 8 August 2016, Mitchell was reviewed by a medical officer with regarding complaints of right shoulder pain. An x-ray revealed a fracture to the right clavicle. Mitchell could not recall hurting his shoulder but remembered being held down by security. Later, Mitchell was reviewed by his treating psychiatrist, who noted that he was feeling quite well and planned for referral to the Alcohol and Drugs Services.
Additional psychiatric reviews on 10 and 11 August noted further improvement in Mitchell's mental health. Mitchell was granted overnight leave to stay with his father on 13 August 2016, and returned to the MHU as planned on 15 August, pleasant, calm and cooperative. It was considered that Mitchell was ready for discharge.
Mitchell was discharged after ten days, on 15 August 2016, as it was considered that his 'psychosis' had resolved. No follow-up plan with a mental health service was organised. He was provided with new anti-psychotic medication, in addition to his normal medications related to his epilepsy. It is suggested that despite indications that Mitchell was willing to comply with his medications, this was not the case following discharge. On 18 August 2016, Mitchell called 000 stating that he had suffered an injury to his shoulder, forgetting about the fracture during the hospital visit. QAS was dispatched to the scene where it was discovered that Mitchell was self-medicating with cannabis. QAS counselled Mitchell regarding his cannabis use and the need for compliance with his prescribed medications.
On 20 August 2016, Mitchell was observed by CCTV deliberately leaning over and falling head first from a third floor balcony at his place of residence, resulting in his death from multiple serious brain injuries.
Root Cause Analysis
A root cause analysis was conducted by the West Moreton Hospital and Health Service, which revealed the following:
- Mitchell had received two craniotomies at age six, due to spontaneous intra-cranial haemorrhage. Significant cognitive changes were observed following this surgery, marked by the onset of seizure at age 12. He started seeing a psychiatrist for major depressive illness and anger management issues in 2007 and resided in multiple foster homes from age 14 to 15;
- Considering the history of seizures, a formal neurological examination or referral to the medical team during the initial presentation to the Ipswich Hospital Emergency Department or admission to the MHU may have been appropriate to exclude a contributory organic condition;
- Incident reports regarding the restraint of Mitchell by security was not reported to the electronic PRIME Clinical Incident;
- Risk factors for suicide, self-harm, aggression, vulnerability and absconding were assessed as low. This was considered inappropriate with respect to Mitchell's background and circumstance;
- No effort was made to organise follow-up mental health support for Mitchell following discharge;
- There was no contact with the MHU psychologist throughout his admission, despite it being recommended considering Mitchell's history;
- Follow-up care by the Acute Care Team would have been appropriate given the possible psychosis and commencement of antipsychotic medication. Further, there was no verification that that Mitchell would be compliant with his medications, particularly as he suggested he self-medicated with cannabis;
- There was a delay in providing the discharge summary to Mitchell's GP.
Recommendations
Two recommendations regarding discharge planning and documentation were formed and implemented following the RCA. First, the 'Acute Mental Health Unit and Older Person's Mental Health Service: Discharge planning' procedure must now be followed by all mental health services. Second, clinical stuff must complete a discharge planning checklist which is to be uploaded to the electronic Consumer Integrated Mental Health application (CIMHA).
Further inquiry
Further detail regarding these findings by Deputy State Coroner John Lock can be found at the link below.
