Matters to be Reported to the Chief Psychiatrist

The Mental Health Act 1996 states that:

The Chief Psychiatrist has responsibility for the medical care and welfare of all involuntary patients (section 9 (1))

In respect of other patients, the Chief Psychiatrist is required to monitor the standards of psychiatric care provided throughout the State (section 9 (2))

Principles

Matters to be reported to the Chief Psychiatrist apply in regard to serious incidents and deaths, which occur in mental health services throughout Western Australia (WA).

Reporting to the Chief Psychiatrist is to be undertaken as matter of priority.

Timely reporting to the Chief Psychiatrist is required in addition to all other reporting requirements which may include: internal management structures, the Director General, Minister for Health, the Office of Safety and Quality (the Chief Medical Officer), AIMS, Internal Audit and Accountability the *Corruption and Crime Commission (CCC) and the Coroner.

As well as the provision of the details listed below regarding a death or a serious incident services are to provide copies of briefings, reports and summaries of investigations even if the Chief Psychiatrist does not specifically request them.

*Corruption and Crime Commission (CCC)

In complying with the reporting requirements of the CCC, health services are not restricted from complying with reporting to the Chief Psychiatrist. The CCC recommendation is that matters can be communicated to the Chief Psychiatrist where they are relevant to the responsibility of ensuring an adequate standard of care to patients.

The CCC (s.7B(3)) is to help public authorities (ie the Chief Psychiatrist) to deal effectively and appropriately with misconduct by increasing their capacity to do so while retaining power itself to investigate cases of misconduct, particularly serious misconduct.

The CCC has the power to prevent the Chief Psychiatrist from investigating an incident of alleged misconduct however aside from this the Chief Psychiatrist is not prevented from exercising his powers under the Mental Health Act 1996 to conduct a concurrent investigation into matters of alleged misconduct.

1.0    DEATHS

The Chief Psychiatrist is to be informed as a matter of priority, of any death of a patient while under the care of any mental health service.  This applies to voluntary and involuntary inpatients and patients cared for in the community.

The information to be provided includes:

1.   Full Name of patient;

2.   Date of birth;

3.   Address;

4.   Voluntary patient, referred person or involuntary patient, (specify whether detained involuntary or on a CTO);

5.   In-patient or community care patient;

6.   Where death took place;

7.   Probable cause of death, eg: Suicide/ accident/medical cause  (this may be just hypothetical until Coroner’s findings);

8.   Known self-harm risk;

9.   Involvement of mental health services;

10.  Involvement of relatives or carers;

11.  Involvement of community members;

12.  Special factors - eg: on special watch, in seclusion, on leave from hospital, recently discharged, person not referred or referred person not admitted, known threats of self-harm or harm to others, medical condition;

13.  Any media interest;

14.  Any factors that implicate the standard of mental health care;

15.  Any other factors.

2.0   SERIOUS INCIDENTS

The Chief Psychiatrist is to be notified as a matter of priority, of any serious incident and associated issue that may reflect on the standards of mental health care in WA. The reporting will include advice as to the potential for media or public implications in regard to the incident or associated issue. 

Serious incidents may include, but are not confined to the following examples:

(a) serious assaults on or by staff, other patients or visitors;

(b) alleged sexual assault on or by staff, other patients or visitors;

(c) serious medication error in regard to a mental health patient, which may require review;

(d) absconding of any forensic patient;

(e) absconding of any detained involuntary patient at serious risk of self-harm or harm to others;

(f)   serious misuse or mistake of a function performed under the MHA;

(g) activity of any government or non-government organisation which is contrary to functions under the MHA;

(h) serious or significant criminal activity, which occurs either in the community or a mental health facility, reported at a mental health facility, and which may receive attention by the media or the police service;

(i)   any incident which by its nature or persons involved may receive attention by the media or the wider community.

The information to be provided includes information above listed 1 to 5 and 9 to 15.

Reporting

Reporting of Serious Incidents and Deaths can be made via e-mail or phone call to the Chief Psychiatrist with a cc to the Manager, Office of the Chief Psychiatrist as soon as possible after the incident.

Should all details of the incident not be available at the time of initial priority reporting then subsequent e-mail or phone advice to the Manager, Office of the Chief Psychiatrist is indicated.

Contact details are:

Mrs Janet Peacock

Phone:            9222 4462

Fax:             9222 4244

E-mail: janet.peacock@health.wa.gov.au

Further Details

Dr Neale Fong
DIRECTOR GENERAL
DEPARTMENT OF HEALTH