A Tasmanian coroner has called for changes to how psychiatric patients are discharged from hospital after a 41-year-old man took his own life weeks after leaving compulsory care.
Coroner Leigh Mackey recently handed down findings into the death of the north-west Tasmanian father of three at his home in November 2023.
The man had been admitted to the Spencer Clinic at the North West Regional Hospital in October 2023 with a manic episode and psychotic features.
He spent 20 days as an inpatient under a treatment order.
Mackey found his discharge sent him back to the same stressors that preceded his illness.
He had nowhere stable to live, was facing prosecution and was in financial trouble.
“Discharge arrangements for psychiatric patients must carefully consider and respond to stressors that may be destabilising on a patient’s discharge,” she said in her recommendations.
A treating psychiatrist revoked the treatment order on November 16, 2023, after concluding the man had regained decision-making capacity. He died 12 days later.
The coroner said the medical records did not show how that capacity assessment was reached, beyond a note that the patient had “insight” and agreed to take his medication.
An independent consultant psychiatrist reviewed the case for the court.
She told the coroner the man’s history of cannabis use and unstable accommodation made future medication adherence unlikely.
The psychiatrist said it was common for patients recovering from mania to fall “into severe depression or into a mixed state of concurrent manic and depressive symptoms”.
The coroner accepted his case worker provided reasonable support in difficult circumstances, noting accommodation options in the state’s north-west are limited.
But she said a follow-up appointment four days before his death, where the man presented as confused about his medication and showed early signs of relapse, warranted a more assertive response.
Mackey’s second recommendation calls for assessments of decision-making capacity under the Mental Health Act to be recorded in writing against all the legal criteria.
The Tasmanian Health Service has been given the findings.
If you or someone you know needs support, contact Lifeline on 13 11 14 or Beyond Blue on 1300 22 4636. In an emergency, call 000.
