A CORONER has found the death of a Dandenong man – who took his own life after leaving a psychiatric ward without supervision – could have been prevented.
In her findings released on Friday 28 August, Coroner Audrey Jamieson said it could be “proved to a reasonable satisfaction” that the November 2011 death of Moufid Sawan, 61, could have been avoided.
Mr Sawan had a “long history of severe psychiatric illness” and was an involuntary patient at the psychiatric unit at Monash Medical Centre in Clayton at the time of his death.
Mr Sawan left the psychiatric inpatient unit at Monash Medical Centre on unaccompanied leave. He committed suicide the same day.
Coroner Jamieson made no recommendations in her report, saying she was “satisfied on the evidence that Monash Health has responded to the identified shortcomings in its care of Mr Sawan and implemented restorative and preventative measures”.
A Monash Health review panel investigated the incident and has since implemented several of its own recommendations, including developing a process for ensuring documented clinical information was readily accessible to all staff, ensuring information from all relevant sources was included in risk assessments and medical record, a review of Monash Health’s ‘leave of absence’ procedure to ensure leave was reviewed in conjunction with a client’s most recent risk assessment and their level of nursing care.
“I acknowledge the difficulty for health clinicians to manage and treat individuals with a mental illness,” Coroner Jamieson said.
“Communication of information obtained about patients to other clinicians is the most effective tool in the development of the skill of analysing and assessing risks that may be attached to the information.
“Documentation of such communication is the means of securing it as a historical record.”
Those in need of immediate assistance can phone Lifeline on 13 11 14.
– LACHLAN MOORHEAD
