Emergency psychiatric care falls short leading to patient death

13 May 2015
A recent coronial inquiry in Victoria has highlighted the problems with providing psychiatric care in an emergency department setting.

A 35-year-old man attended the Dandenong Hospital emergency department at 4:30am one morning reporting that he was hearing voices telling him to kill himself. He was also anxious, sweaty and shaking. The patient had stopped drinking after a long history of regular alcohol consumption but had no prior history of any mental health problems.

He was initially assessed by a registrar in the ED, who contacted the psychiatry team for review. The patient was then assessed by a psychiatry registrar at 10:00am, who noted that he was still hearing voices commanding him to kill himself and that he had a low mood and speech. It was also noted that the patient was exhausted and was suffering physical symptoms of nausea, fatigue and hand tremor. The registrar made a diagnosis of acute alcohol withdrawal but also raised the possibility of having a psychotic episode.

Following this assessment, the designation of the patient’s bed was changed to the Psychiatric Assessment and Planning Unit (PAPU), although he remained in the same bed in the ED.

Following this assessment, the patient was not reviewed by any staff from either the medical or psychiatry team at any point during the day. However, at 11.05pm that night, he was given a dose of Olanzapine PRN (as needed) although the records did not contain any note explaining who ordered it or why it was required. During the inquest it was claimed that  given the dose was administered “PRN” the patient was exhibiting symptoms that required treatment.

At around 4:00am the following morning, a psychiatry registrar was paged to review the patient prior to discharge. There was no record of who ordered the review or contacted the registrar. At the Inquest, the registrar gave evidence that the patient said he wanted to go home and she thought he was fit for discharge but did not discuss the case with a consultant. The registrar asked whether she could call the patient’s wife but he replied that he did not want her called because she could not drive. The registrar did not ask whether other family members could be called and the patient was subsequently discharged on his own at around 4:30am.

Unfortunately, the patient never returned home and his body was found in the creek adjacent to the hospital a few days later. The cause of death could not be determined but it was clear that the patient had attempted to cross the creek in the dark and something had happened. Other causes of death, like unrelated illness or foul play, were ruled out.

At the inquest it was alleged there was ongoing confusion among staff about who was responsible for the patient after his bed designation was changed. Psychiatry staff gave evidence that they expected the ED medical team to continue management, yet nursing staff gave evidence that they thought the patient was under the care of the psychiatry team.

The registrar who discharged the patient said there was no verbal or written handover from the ED medical team, she was not aware of the treatment he had received (including the PRN dose of Olanzapine five hours earlier) and had assumed that the ED medical team had performed a comprehensive review before deciding to discharge him. In fact, the patient still had not been reviewed by anyone from either the ED medical or psychiatry teams after the assessment at 10:00am the previous morning.

The patient’s family argued that the result of this confusion and lack of communication was that the patient was discharged without adequate assessment and that it was inappropriate to do so given his history and symptoms.

It also became clear during the inquest that little thought had been given to contacting the patient’s family prior to discharge and the patient’s request not to call his wife was borne from practical considerations and had nothing to do with his privacy. In fact, his wife, parents and sibling had been present throughout the stay and were well aware of the nature of the admissions and treatment. The family argued that discharging the patient into his own care at 4:30am was inappropriate and directly contributed to his death.

Cases such as these demonstrate how important it is for hospital staff to follow standard procedures regarding assessment and management of patients and to ensure documentation of treatment plans so there can be continuity of care. Poor communication in the multi-disciplinary context, particularly in a busy emergency ward, is understandable but not excusable given the outcome could be the loss of life.  

The Coroner’s findings in this case are still pending. It is important to note that the role of the Coroner is to make a determination on the manner and cause of the death. There is no requirement for the Coroner to make findings on legal negligence, rather this is the function of civil litigation, where compensation is sought by the family who depended on the deceased.’

By Tom Ballantyne