A root cause analysis was carried out by the hospital (Richmond Clinic) after the event. It reveals some startling facts about the care and handling of information regarding the mental health patient.

Before reading ahead, place one hand under your chin to counter the potential for jaw drop.

1.   “An underestimation and lack of systematic assessment and documentation of risk in a man with a significant past history of repeated violence led to an inappropriately coordinated and non assertive community care plan which did little to address the situation or recurrent relapse and associated violent behaviour.”

2.   “Limited inpatient discharge planning did not include all agencies contributed to an inappropriate risk (of violence) assessment and non assertive community mental health care plan which may have contributed to the likelihood of the client’s symptoms escalating and going unnoticed.”

[In the report “Tracking Tragedy 2008 – Fourth Report of the NSW Mental Health Sentinel Events Review Committee”, it was highlighted that communication issues are consistently a major factor in studies of preventable medical error. It would appear that the warnings of the Mental Health Review committee went unnoticed.]

3.   “Poor communication between Health and HASI [a Housing program run by On Track Community Programs] staff in the care of a man with a predictable risk of violence may have contributed to a lack of interventions for ensuring strategies for detecting and responding to increased violence were in place.”

As indicated in the report on each of the above points, communication was lacking in all areas, as was knowledge, skills and competence.

However, unlike the organisation that Michael worked for, the hospital through its Root Cause Analysis had shown it was ready to investigate and take responsibility for the failures and to put into action recommendations for an improvement in health delivery standards. Would it have been too much for On Track Community Programs to be as clear and transparent as Richmond Clinic had been?

In the 2008 Tracking Tragedy report, the summary paragraph on homicide likelihood by a mental health patient reads as follows:

“Those who cause serious, potentially fatal violence are likely to be unemployed, have a chronic schizophrenic illness, be substance abusers and have a history of violent behaviour. Those with severe mood disorder are another significant group. In the case of people with a psychotic condition, delusional belief that they are under threat is a common phenomenon.

A history of violence was a common characteristic (64%) of those suffering from a mental illness who committed homicide or caused serious injury.”

The above paragraphs accurately describe the perpetrator of Michael’s murder. It would appear that the clinic and the On Track Lismore manager had failed to read this report and be proactive in preventing a homicide. Then again, the report also states that Communication is an issue.