‘Deficient’ system aided homicide spate

Poor co-ordination between services and out-of-date assessment methods have contributed to the pressure in WA’s mental health system.

‘We’ve still got a desperately underfunded and fragmented mental health system and despite all the rhetoric, things have not improved’: Greens spokeswoman for mental health Alison Xamon

A spate of homicides in Western Australia by mental health ­patients could have been avoided were it not for a host of deficiencies in the state’s mental health system, a review from the office of the state’s chief psychiatrist says.

It found the state’s mental health system was under significant pressure, with poor co-ordination and co-operation between services, out-of-date assessment methods, insufficient funding and a flawed organisational structure all contributing to the situation.

The review examined the “root cause analyses”, or RCAs, and other documentation from health service providers after nine people were killed in 2018 by people in contact with or treated by WA mental health services.

Common themes between the homicides included a failure to recognise and respond to signs of deterioration, including a lack of engagement between hospital emergency departments and other parts of the mental health service, and a “reluctance” to respond to concerns raised by family members and carers.

“In a number of the RCAs, it is clear that the individual’s mental state was deteriorating and that had this been adequately appreciated, a more rigorous treatment approach could have been implemented that may have changed the outcome,” the report said.

It found there had been “no shortage” of earlier reviews and recommendations that identified similar problems and made similar recommendations without any lasting change in practices.

“The question could legitimately be asked about why all these reviews and reports have not been able to significantly change the quality and safety of mental health services — and, more importantly, what do we need to do to facilitate the change,” the report said.

There appeared to be an “over-reliance” on checklist risk assessment tools that had been found to be “meaningless” as a predictor of a patient’s risk to themselves or others, while there was no evidence in any of the cases that risk management plans had been developed for any of the patients in question.

“It is clear from the RCAs and associated reports that the Department of Health’s recent policies on risk assessments and manage­ment for suicide and violence and aggression have not been widely implemented by the [providers],” the report said.

There was also a “clear” reluctance in several cases for patients to be admitted as inpatients, with some repeatedly assessed in emergency departments or advised to seek treatment from a GP rather than seek assessment from mental health specialists.

The report said in several incidents patients were treated as having a “drug toxicity’’ and underlying personality disorder, even where they had previously had a clear diagnosis of schizophrenia or schizoaffective disorder. “Obtaining a full mental health history, seeking collateral information from family members/carers wherever possible and allowing a longer period for observation would go a considerable way to clarifying a person’s diagnosis,” the report found.

Alison Xamon, the Greens spokeswoman for mental health, said the findings should be of “grave concern” to everyone and noted that the spate of homicides had all occurred under the current state government. “We’ve still got a desperately underfunded and fragmented mental health system and despite all the rhetoric, things have not improved,” she said.

The nine homicides included an alleged triple murder by one patient. Of the nine victims, seven were family members of the ­alleged offender.