Inquest into the death of Jordan Allen

CITATION: Inquest into the death of Jordan Gregory Allen

[2019] NTLC 029 TITLE OF COURT: Coroners Court JURISDICTION: Alice Springs FILE NO(s): A0011/2018 DELIVERED ON: 27 September 2019 DELIVERED AT: Alice Springs HEARING DATE(s): 11 September 2019 FINDING OF: Judge Greg Cavanagh CATCHWORDS: Mental Health Facility, involuntary patient, “cigarette leave” while still psychotic, took his own life

REPRESENTATION: Counsel Assisting: Kelvin Currie Counsel for Central Australia Health Service Stephanie Williams Judgment category classification: A Judgement ID number: [2019] NTLC 029 Number of paragraphs: 79 Number of pages: 20

IN THE CORONERS COURT AT ALICE SPRINGS IN THE NORTHERN TERRITORY OF AUSTRALIA No. A0011/2018 In the matter of an Inquest into the death of

JORDAN GREGORY ALLEN ON: 1 FEBRUARY 2018 AT: 2 GAP ROAD, ALICE SPRINGS FINDINGS Judge Greg Cavanagh Introduction

1. Jordan Allen (the deceased) was born 25 July 1983 in Shepparton, Victoria to Carol Anne Allen and Gregory Robert Allen. His parents separated when he was 5 years of age. His mother took her own life four years later.

2. Jordan was raised by his father and Kim, his father’s partner. His father and Kim had two further children. Jordan had a troubled youth. He felt that he didn’t “fit in” with the family. He began to abuse illicit substances. He seemed lost. His father arranged for him to speak to counsellors, particularly in relation to the loss of his mother. However he wouldn’t engage with the counsellors.

3. Jordan left school at year 10 and commenced a butcher’s apprenticeship. He didn’t finish. He left home at the age of 17 years and went to Echuca where he worked at an abattoir. He moved to Alice Springs in 2010 and since 2015 worked with his father in his father’s cleaning business.

4. During his time in Alice Springs, Jordan had a significant relationship with Jess. They lived together for about a year. When the relationship ended she moved to NSW. She died of an overdose of prescription medication in December 2015. Jordan took her death very badly. There was some dismissive communication to her not long before her death. He believed he could have done better.

5. From that time Jordan’s use of methamphetamines appeared to increase. His father noted that he became paranoid.1 Jordan thought people in cars were following him and felt vulnerable when having showers. If he took showers they were quick. He often slept in his clothes for the same reason. His paranoia continued at various levels until his death.

6. On 12 April 2016 he attended on his General Medical Practitioner. He said he always suffered anxiety but since the death of his girlfriend five months previously his anxiety had become severe. He said his work and sleep were affected. He said he smoked 20 cigarettes a day but denied drinking alcohol.

He undertook a psychological test and was started on the antidepressant, Sertraline.

7. He attended on the psychiatrist Dr Bernard Hickey. On 28 September 2016 Dr Hickey wrote: “Self presents because he thinks he has attention disorder, doesn’t keep on top of things, can’t keep up with anything … Hard to settle, drinks at times, some cannabis and gambling when younger … Constantly talks over people. Task completion poor … On examination well presented, talks rapidly, a bit anxious, mood and affect otherwise normal, thought rate and form normal. Has good insight.

Presented school reports from prep and grade 1 confirming attention deficit hyperactivity behaviours.

1 CCIS note 31 January 2018

History and exam and school reports are consistent with ADHD. I will start Ritalin 10 mg three times a day after getting authority from Drugs and Poisons

NT.”

8. On 24 October 2016 Jordan told Dr Hickey that he couldn’t get used to the medication. He said he felt “zombie like and on edge as well”. Dr Hickey changed the prescription to Dexamphetamine sulfate 5mg to be taken 4 times a day.

9. Jordan saw Dr Hickey the next month on 16 November 2016. He said he was able to listen, organise, was more motivated, sleeping well and waking up better. On 13 December 2016 when he saw Dr Hickey he was noted to be looking well. He said he was getting things done and was really happy. On 24 January 2017 he said he was organised and not depressed although he said he wasn’t having much fun. Dr Hickey observed that he looked a little tired.

10. Thereafter Jordan saw Dr Hickey about every three months. On 4 October 2017, Jordan told him that he was happy with the medication and didn’t want to increase the dose. He said he wanted to keep it as low as he could for as long as he could.

11. Jordan later said that sometime before Christmas 2017 he had been “hitting the ICE”. He said it “really set him off.”2 He was of the belief that people in the drug trade were out to kill him. He appeared to be worried for his family and said he started to take more prescription dexamphetamine to stay awake.

12. When he saw Dr Hickey on 16 January 2018, Jordan said that he didn’t think the dexamphetamine was working as well. He said he had taken time off work as he needed a break from the stress of the business. He said he was 2 CCIS notes 1 February 2018

having problems concentrating. Dr Hickey increased the dexamphetamine to 10mg 4 times a day with the plan to review in a month.

13. It seems that shortly after that consultation Jordan began taking much more of the prescription dexamphetamine. His father said that he didn’t sleep for 5 to 7 days approaching his admission to hospital on 29 January 2018. He was paranoid that he and his family would be killed.

14. On the evening of the 22 January 2018 Jordan was at his flat. His father found him to be “freaking out” and suggested that Jordan come and stay with them. In the early hours of the following morning (23 January) Jordan was found with a torch looking at the outlet of the air conditioner. Jordan said that he could see a microphone. His father noted it to be the seam in the sheet metal.

15. At about 2.20am on 24 January 2018 Jordan rang “000” saying persons were trying to get through the window. Police attended and patrolled the area. At 3.30am on 25 January 2018 Jordan again rang “000”. He said that people were trying to break through the roof to kill him and his family. He was also suspicious of the call-taker and wouldn’t answer the questions. He believed that those that wanted to kill him had access to the telephone lines.

16. Police attended but he thought they were the killers disguised as police. He refused to open the door or let his father open the door. At one point he tried to light a tea-towel to create a diversion and get the fire-brigade there.

Police entered by the rear door and took him to hospital. However, on arrival he seemed calm and coherent and was released into the care of his father. He apologised to his family on return to the home.

17. His family were concerned that the house might have caught fire and were uncomfortable with him staying there. The next night (25 January) his father went to stay with Jordan at his flat. Jordan was paranoid that night about the

noises and thought the killers were pumping chemical in through the air conditioning. Jordan left his flat and booked into a hotel under a different name for the rest of the night. His father stayed at the flat to prove there was no one trying to kill him.

18. The next night (26 January) Jordan drove around in his truck throughout the night and the following night (27 January) Jordan asked his father for the business Hi-Ace van. His father thinks he likely spent the night in the back of the van looking out the window.

19. The next day Jordan wanted to leave and fly to Victoria. His father took him to the airport. However, they were too late for the flight and couldn’t get a ticket at the airport. On the way back from the airport Jordan used his father’s phone to call the Victorian Police.

20. He told them he was being followed. They called the NT Police. Police called Jordan’s father and then attended the premises to speak with Jordan.

He said he was feeling better and knew he needed help. He said he would attend the Mental Health Unit in the morning. Jordan’s father assured police they were safe and he would take Jordan to the Mental Health Unit the following day.

21. At about midday on 29 January 2018 Jordan agreed to go to the hospital with his father. The letter on admission stated: This 34 year old man … was admitted as a consequence of overuse of prescribed dexamphetamine and perhaps coupled with use of methamphetamine as well. He had become quite paranoid and agitated and was not able to be kept at home … When I saw him on the ward he was extremely agitated and quite guarded, but it was quite apparent that he was very, very paranoid making allusions to people who were going to harm him, that he was in danger.

He was quickly integrating the ward staff into his delusional system – that is to say there were strong indications that we were seen as

part of a paranoid conspiracy to kill him, and at times during our attempts to calm him down and give him medication, alluded to the fact that he would never leave the ward alive.

We did manage to get him into the high dependency unit and get him to take some olanzapine … which settled him fairly well.

I do think this man has probably had an ongoing lingering paranoid delusional system for some time. We completed the paperwork to switch him from voluntary to involuntary status.”

22. He was formally admitted to the Mental Health Unit at 3.40pm. He was psychotic and agitated. From the time of his admission he was unhappy about being detained. He was paranoid someone in the hospital would kill him and he desperately wanted to go outside to smoke.

23. On 29 January 2018 (the day he was admitted) he is recorded as saying: “I can go home tomorrow and live my life with no problems. I don’t need to be here”. He was said to be “ravenous” at dinner time and then from about 7.00pm slept soundly on the couch all night in the High Dependency Unit (HDU). His father stayed as a boarder overnight.

24. The next morning (30 January) he woke at 9.30am. He ate a small breakfast and then was seen for psychiatric review. No formal thought disorder was noted. He said he understood that he had been paranoid. It was said that he was fixated on cigarette leave and discharge. When that was denied he became oppositional. He was demanding to speak to his “own” psychiatrist.

25. In the nursing note two hours later (just after midday) it was said: “Continues to present as paranoid, entitled, oppositional, guarded, labile, brittle with nil insight into current situation … continues to request immediate discharge”

26. At 2.09pm the notes state:

“Presentation unchanged. Underlying irritability evident due to admission … remains angry that he is in hospital.”

27. The next day, 31 January 2018, it was noted that he seemed to be tired throughout the morning shift. He was said to be paranoid and apprehensive about transfer to the open ward. He continued to ask to go out to smoke.

28. At 2.18pm it was noted that he thought the security guard was a likely hitman. During a consultant review at that time it was considered that his delusions seemed more long-term than a drug induced psychosis and that he may be suffering an enduring delusional disorder or schizophrenia.

29. An hour later during a Registrar review, Jordan said that he was feeling good and was keen to go home. He said that he had been fine until a few days before Christmas when he started to get a bit paranoid. He said he “thought people were following me”. He said he then “hit the Dexi pretty hard” which “made things worse”. He said he wanted to leave hospital that evening and get back to work.

30. Shortly after that review however, his presentation changed and he became agitated and paranoid about one of the security officers in the HDU. He said he wished to speak to a lawyer. He then wouldn’t go into the Low Dependency (LDU) Unit for dinner because of a man in the LDU he feared.

31. Jordan had a cup of tea that night at about 9.30pm. Shortly after he began screaming, saying he had chest pain and pain in his left arm. He would not allow observations to be taken, shouting, “get this shit off me, take me to ED”. The emergency team were called and they transferred him to ED. It was surmised that he may have been experiencing the effects of withdrawal from methamphetamines.

32. He slept well that night and in the morning had no residual pain. He told the nurse that he was ashamed of his behaviour the night before. He was visited

by his private psychiatrist, Dr Hickey, and apologised to him for lying about his past substance abuse so as to get the Dexamphetamine. He said he had no paranoid thoughts but had real concerns over drug dealers to whom he owed money. He was seen to be “eagerly pacing and wanting to have a smoke” while transfer to the LDU was being arranged.

33. At the consultant review that morning when discussing a transfer to the LDU, Jordan said he had concerns about a “certain person” in LDU who “knows me”. He said “this is not paranoid, he knows me”. He was assessed as having “ongoing paranoid ideation, impaired judgement owing to ongoing psychotic/persecutory thinking”. It was considered that there had been some improvement since admission. The plan was to transfer him to the LDU and give him escorted leave “4x15 minute escorted leave”. He was transferred to the LDU at 11.05am.

34. He got his wallet, cigarettes and lighter from his property and left the ward with his father at 11.15am. The purpose of the leave was to allow him to smoke. He lit a cigarette and he and his father walked to the Coles Express across the road to buy more cigarettes and a can of Red Bull. They were walking back and Jordan began to light another smoke. His father said, “make it quick mate, we’ve got about a minute and a half to get back”.

35. By that stage they had crossed Bagot Road from the Coles Express and were near the entrance to the MacDonnell Shire Council. Jordan stopped. His father turned to him and saw terror in his face. Jordan said “I can’t, I can’t, I can’t go back”. He started heading through the gate of the Council property.

His father followed and Jordan said, “don’t come with me they’ll kill you too”. He looked at his father and said “I love you dad, goodbye”. He then ran in the direction of the Todd River. His father returned to the hospital and reported what had happened. At 1.42pm the hospital reported Jordan missing to Police.

36. Four days later in the early morning of 5 February 2018, a worker at the Centralian Advocate noticed a bad smell near the car park. A trail of blood stained decomposition fluid was observed to be coming from the shed.

Police were called. They entered and found the Jordan hanging by one of his shoe laces attached to an overhead beam. It was obvious that Jordan had been deceased for some days. Given the extent of the decomposition and the proximity to where he was last seen it is likely he took his life the same day he absconded.

37. The Police investigation found no suspicious circumstances in relation to Jordan’s death and found no evidence that any person was following him or trying to kill him.

Leave

38. The Mental Health and Related Services Act (the Act) makes provision for the granting of leave to patients even while admitted involuntarily. The relevant part of the Act is as follows: 166 Leave of absence (1) This section applies to a person who:

(a) is admitted to an approved treatment facility as an involuntary patient; and

(b) is not a prisoner.

(2) An authorised psychiatric practitioner may grant the person leave of absence from the facility.

(3) Leave of absence:

(a) must not be granted except in accordance with approved procedures; and

(b) must be recorded in the approved form; and

(c) is subject to the conditions determined by the practitioner.

39. In effect the Act, provides that a person may be granted leave from the Hospital so long as three preconditions are fulfilled: a. The leave must be in accordance with approved procedures; b. The leave must be recorded in the approved form; and c. The leave is subject to the conditions determined by the authorised psychiatric practitioner.

Approved Procedure

40. Approximately six weeks prior to Jordan’s admission to the hospital the Mental Health Service produced procedures for the first time. That had been in response to another death where the patient took his own life while on leave on 17 October 2017.3 The procedures were titled, “Authorisation of Leave s166 MHARS ACT Standard Operating Procedure”. The procedures were approved on 13 December 2017.

41. The procedures, in part, state: “Clients and carers should be involved in leave planning and clients should take leave in the company of family and friends whenever possible based on assessment of risk and discharge planning process … Staff do not accompany clients on leave except by agreement with the treating team and in compliance with an overall staged discharge plan … Staff do not escort clients for the purpose of smoking”.

42. Under the heading “Authorisation Procedure (For APP’s)”, the following is found: “All considerations of leave status (escorted, unescorted, duration, frequency and other parameters such as where) are to be considered and documented in the Multidisciplinary Team (MDT) Ward Round (at least once per week with the MDT Ward Round Template found 3 Inquest into the death of Linden Kunoth[2019] NTLC 028

in CCIS Document template that is to be signed by the treating Psychiatrist prior to the end of the ward round and scanned into CCIS and the hard copy file); All clinical assessments and decisions regarding leave status are to be DOCUMENTED in the clients electronic health record CCIS.”

43. There is no reference specifically to “cigarette leave”. Although it might be inferred that the authors had that in mind by the indication that staff were not to escort clients for the purpose of smoking.

Approved Form

44. The Mental Health Service has an approved form titled, “Form 51 Leave of Absence Approval and Agreement”. There are two major parts to the form as it relates to involuntary patients. The first is titled “Part A” and makes provision for the approval by the Authorised Psychiatric Practitioner (APP).

The second, “Part B” purports to be an agreement by the escorting carer that they understand that the patient remains an involuntary patient, is merely on leave and agrees to report to staff on how the leave progresses.

45. The procedures state that the Form 51 is to be: “authorised and signed by treating Doctor, and once original copy is completed and signed by approved Family Member/Escort, a copy is made and given to Family/Member/Escort and original is placed in clients hardcopy file.”

46. The actual form for the leave granted to Jordan is reproduced below:

Conditions

47. The Form has wording: “The period of leave is subject to the following conditions”. There is then a space. However not sufficient, it seems, to list the conditions. The practice appears to have been to write the conditions in the “free space” on the form.

48. The conditions written on the form were: “EL with father” and “4x15 min”.

What that meant was that the conditions for leave were that Jordan had to be escorted by his father and that the leave could be for four periods of 15 minutes during the day.

49. The approved procedures note that the determination as to whether or not to grant leave is based on two aspects, the “risk” and the “discharge planning process”.

Risk

50. There is no guidance as to what risks to take into account. The obvious ones however were the risk to himself and others and the risk of absconding.

There was little noted as to there being a risk to himself and others, however, there was a consistent theme throughout his stay in the Mental Health Unit that he did not believe he was unwell, did not want to be there, thought he was liable to be killed while there, and wanted the intervention of a lawyer or his own psychologist to enable him to leave. The risk of him not returning was conceivably very high.

51. His father had managed to talk him into going to the hospital on 29 January

2018. However having been detained for just over two days in circumstances where he considered himself to be at risk and, to his mind, there being no benefit to him in staying, it was always going to be difficult to get him to return.

Discharge Planning Process

52. The approved procedures anticipate leave to be a part of the discharge planning process. I was told that is also the principle behind the leave: “One aspect of the psychosocial recovery of patients, and the transition to the community, is having escorted leave from the MHU, while in the recovery phase.”4

53. However, the leave was not provided as part of a discharge planning process. Nor was Jordan in the recovery phase. That was conceded.5 Rather, leave was provided simply to allow him to smoke. I was told that due to the Health Department’s smoke free policy, if smoking is to be allowed it must be off the campus.

54. Given that he was a high risk of absconding and the leave was not part of the discharge planning process it appears that “cigarette leave” was granted without adherence to the approved procedures.

Mitigation of Risk

55. The position Jordan’s father found himself in was both impossible and tragic: a. He was apprehensive about his son being granted leave, however there was not sufficient discussion by the treating team to understand his reservations; b. There was no discussion as to what he should do if his son did not wish to return; c. There was no information as to who to call if he encountered problems while supervising the leave.

4 Statement of James Goodbourn para 25 5 Transcript p 28

56. Even if it had been in accordance with approved procedures, allowing any patient leave who is suffering psychosis poses significant risks. Such patients are liable to be unpredictable. Those risks need to be mitigated. The processes for that mitigation are not well supported by the approved procedures, the Form 51 or the practices that have grown up around the granting of leave.

57. The risk to Jordan was significant. The only mitigation for that risk was the presence of his father. Any confidence in that mitigation being sufficient could only be determined after a conversation by the treating team with his father. That should have occurred out of hearing of Jordan. It could be potentially destabilising to the relationship between the father and son if the father expressed his actual views in the presence of his son.

58. That was readily agreed by Dr Goodbourn. He said: “My contention is that a thorough review of the carer who is likely supervising should be undertaken, and those subtleties ideally would be understood in that conversation … because otherwise we don’t get a full understanding of what the potential supervisor is feeling; about their willingness, about their capacity; and ideally we explore possible scenarios, like, what happens if your son or daughter walks off or runs off; are you confident that you can manage that, if it does happen what do you do … so the whole process is explored.”6

59. Logically, that conversation must come before a decision to grant the leave because leave should not be granted unless there is confidence that risk is properly mitigated. If that conversation happens and leave is to be granted, the necessary conditions of that leave are likely to be much better understood and better defined by the treating team.

60. A process to support that conversation would require the conversation, the setting out of the conditions, the agreement to those conditions by the 6 Transcript p 31

parent/escorting person and the signature of escorting person on the Form prior to the granting of leave. That is, on all matters where there is significant risk the conditions of leave should be clearly set out on the Form and Part B of the Form signed prior to approval for leave being granted by the doctor (Part A).

61. However the approved procedure did not mention a requirement for such a conversation, there was no suggestion of risk being mitigated or the process to follow to ensure that happened. It was simply assumed that if an APP signed the Form 51 all risks were being appropriately managed.

62. Form 51 is also ill-adapted. There is not sufficient space to clearly set out the conditions on which leave is granted and no information on the form as to what to do or who to call if the unexpected happens.

63. There was also no understanding that the person granting the leave should be the person signing the document or explaining the process to the escorting relative or friend. The impression given was that the way the Form 51 was completed in this case was the usual way. That is, the consultant on the ward round made the decision for leave to be granted. The Registrar that was with the treating team when the decision to grant leave was made then asked the Resident Medical Officer (RMO), (who was not with the treating team on the ward round) to complete the paperwork.

64. The RMO did not talk to the father and was not expected to do so. The expectation was that after the RMO had signed the Form 51, the nursing staff would get the father to sign Part B and any questions about the process would be answered by the nurse.

65. By the time the father was requested to sign the Form 51 the decision to grant leave had been made and the authority for the leave had been signed by the RMO. It was a fait accompli that leave was being taken. That was a

very invidious position for a father having reservations about the leave being granted in the first place.

The Form

66. In effect the Form 51 in use has no connection with the approved procedures and no legible information useful to the escorting carer or patient about conditions upon which leave is granted or what to do when those conditions are breached.

67. Having heard that the RMO signing the form had nothing to do with the decision to grant the leave, I said during the inquest: “It makes a mockery of the form when that happens doesn’t it? You may as well not have the form if the person signing off on it had nothing to do with and no responsibility for the decision-making or communication.”7

68. Providing a copy of it in that form to the escorting carer has little benefit.

That issue, at the suggestion of Jordan’s father, has more recently been sought to be addressed by the provision of a business card with a phone number. However, it is clear that the Form itself needs to be made useful by being integrated with the approved procedure and the conditions of leave being a prominent and legible feature, along with the information of what to do and who to call if things do not go well.

Smoking

69. Because Alice Springs Hospital is a smoke free campus, there has been some uncertainty as to whether smoking should be allowed on the campus for mental health patients. The result has been the provision of nicotine patches and other substitutes along with “cigarette leave”. When taking cigarette leave, the patient is required to leave the campus. They stand on the footpath outside the hospital or in a public carpark adjacent to the hospital to smoke.

7 Transcript p 24

Even without the facts of this case, it does not take too much imagination to think that might not be the most appropriate solution.

70. I expressed my views during the course of the inquest in these terms: “As a general proposition, and in my view as a matter of common sense, if you are dealing with an agitated, acutely mentally ill patient who is psychotic and you are trying to calm him or her down with medications and chemicals, I don’t see a particular problem letting them have access to nicotine if they are so addicted to it. They’re not there, after all, to be weaned off tobacco...

So I don’t see any particular problem with a 15-minute smoke break for someone who is agitated, psychotic, and you want to calm him or her down. The question is the nature of that break. Ought it be seen as another form of leave under the section of the Act, or should they be allowed to go to some other secure part of the hospital to have a fag so they can’t run across the road and kill themselves.”8 That is obviously a policy issue for the Hospital to resolve. I have little doubt however that it was the lack of a safer option that lead to Jordan being given leave contrary to the approved procedures and before he was in the recovery phase.

Step-wise graduation

71. One other process I was told was used to assess patient’s response was a step-wise graduation. The relevance for these facts is that Jordan had been held in HDU. It was determined at the ward round that he would be trialled in the Low Dependency Unit (LDU). It was known there was a person or persons in the LDU he feared. It was not understood whether he was likely to see others outside who he might fear or what his reaction would be in such circumstances. However, he was in the LDU for only 10 minutes before he was walking out the door for leave. It was conceded that he should not have been given the leave at the same time as being trialled in the LDU.

8 Transcript p 29

Comment

72. Jordan should not have been given leave. He was psychotic. He had not been trialled in the LDU. He had no insight as to why he should remain at the Hospital and had since his admission been seeking to leave. He was high risk. He was not in the recovery phase and discharge planning was not at that point on the horizon.

73. There was no appropriate conversation had with his father who was nominated as the escort. His father understandably had significant reservations. It was only a few days before that he had managed to get Jordan to the Hospital. It was a desperately terrible situation in which to put a caring parent.

74. Alice Springs Hospital and the Central Australian Mental Health Service have put a great deal of effort into attempting to modify their systems following the deaths of Jordan and another patient in similar circumstances.9

75. I am told that Form 51 is being reviewed. As noted above, in my view that is needed. As is some revision of the approved procedure to make it plain that where there is significant risk, the discussion and form filling with the escorting carer must precede the decision to grant leave.

76. I do however commend the Alice Springs Hospital and their Acting Director, Mr Jim Goodbourn on the frankness of their reflection and the demonstrated willingness to learn and improve.

Formal Findings

77. Pursuant to section 34 of the Coroner’s Act, I find as follows:

(i) The identity of the deceased is Jordan Allen, born on 25 July 1983 in Shepparton, Victoria.

9 Inquest into the death of Linden Alan Kunoth [2019] NTLC 028

(ii) The date of death was 1 February 2018. The place of death was a plant room at the Centralian Advocate at 2 Gap Road, Alice Springs.

(iii) The cause of death was self-inflicted hanging.

(iv) The particulars required to register the death:

1. The deceased was Jordan Allen.

2. The deceased was of Caucasian descent.

3. The deceased was a cleaner.

4. The death was reported to the Coroner by Police.

5. The cause of death was confirmed by Forensic Pathologist, Dr John Rutherford.

6. The deceased’s mother was Carol Anne Allen and his father was Gregory Robert Allen.

Recommendations

78. I recommend that the Central Australian Mental Health Service resolve the issues around whether involuntary patients should be permitted to smoke and if so, provide them with a safe place to do so.

79. I recommend that the Central Australian Mental Health Service ensure that its approved procedure and Form support appropriate risk assessment prior to the decision to grant leave, that the Form has sufficient space for conditions to be legibly written and appropriate information for the escorting person as to what to do and who to contact if things go wrong.

Dated this 27th day of September 2019.

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GREG CAVANAGH TERRITORY CORONER