Hospital failed to source contact details of Jackson Desmond David Stawicki who was later found dead

Hospital staff failed to gather the contact details of a patient who was found dead weeks later, a coroner has found.

A 24-year-old man died weeks after presenting to the emergency department multiple times. Picture: Mitch Bear

A Belmont man was found dead weeks after three consecutive presentations to Geelong hospital’s emergency department.

Jackson Desmond David Stawicki’s death was the subject of an inquest, with a coroner finding staff at Barwon Health failed to gather the man’s up-to-date contact information, despite being ordered to conduct a follow-up check.

Just weeks before his death, between September 4 and 5 in 2020, Mr Stawicki was taken by police or ambulance to Geelong hospital multiple times and apprehended under the mental health act.

According to court documents, the first presentation, about 10.35pm on September 4, occurred after police were called to his share house Waurn Ponds after Mr Stawicki became embroiled in a dispute with his housemates.

Coroner Paresa Spanos noted Mr Stawicki, 24, was “agitated” upon arrival to hospital and told clinicians he had used multiple drugs.

He was given anti-anxiety and antipsychotic medication.

Hours later, about 12.23am on September 5, Mr Stawicki was reviewed by a mental health clinician.

While he was found to be substance affected, the clinician did not believe he had active-psychotic symptoms and a discharge plan was made, with plans put in place for a community follow-up from the Child and Youth Triage Team.

Mr Stawicki was also provided with contact number for crisis and addiction services before being sent home in a taxi.

The court noted Mr Stawicki became aggressive toward the taxi driver and police were called again.

He was sent home at 1.23am.

About an hour later, police returned to Mr Stawicki’s house amid reports he was damaging property.

Police were told Mr Stawicki had alternative accommodation in Belmont, where he went.

At 3.34am police attended that address amid concerns he was trying to self-harm.

He was again arrested under the mental health act (MHA) and taken to Geelong hospital.

Paramedics, who noted Mr Stawicki was experiencing hallucinations and displaying “bizarre behaviours”, administered a drug to reduce his manic symptoms.

He was admitted to hospital and slept for several hours but was still “aggressive and agitated” when he woke.

Mr Stawicki was reviewed by a clinician who noted he was not acutely substance affected, did not have psychotic features but admitted to self-harm.

According to the report, the clinician found Mr Stawicki’s behaviour was “predominantly anti-social and did not meet the criteria under the MHA for a compulsory treatment order”.

He was discharged that night under the condition that he undergo a “community care follow up”.

Days later, on September 7, Mr Stawicki was sent a letter by the follow-up team but failed to engage.

He was found dead at his home on September 22.

Ms Spanos found that while Mr Stawicki received “reasonable and appropriate care” at hospital, Barwon Health staff “failed to obtain current contact details for Jackson, including an updated address and critically his mobile phone number”.

“It is clear that Jackson needed help in the community to address his mood disorder and substance abuse,” she noted.

“Suboptimal management of Jackson’s discharge by failing to obtain essential contact information rendered him vulnerable and without supports that might otherwise have been provided if he had engaged with the CYTT.”

Ms Spanos noted the case highlighted the need for all staff in clinical settings to ensure patient information was up-to-date.

A Barwon Health spokeswoman said the findings had been received and would be considered.

If you or anyone you know needs help, call Lifeline on 13 11 14.

Originally published as Hospital failed to source contact details of Jackson Desmond David Stawicki who was later found dead