Thredgold Coronial Inquiry Recommendations

Ms PRATT (Frome) (14:31): My question is to the Minister for Health and Wellbeing. Have the four recommendations from the Thredgold coronial inquiry been implemented; if not, why not? With your leave, sir, and that of the house, I will explain.

Leave granted.

Ms PRATT: The June 2022 inquest examined Mrs Thredgold's death, including her social, medical and psychiatric history, the events leading to her admission to the RAH, and the failings of the hospitals and individuals in her treatment. Systemic failings were examined, with recommendations made to reduce the likelihood of other deaths in similar circumstances. SA Health received and accepted all four recommendations at the time.

The Hon. C.J. PICTON (Kaurna—Minister for Health and Wellbeing) (14:32): I thank the member for this other important question. I have had the pleasure of meeting with James Thredgold, Holly's husband, when the recommendations were released, and committed to him that the government accepted all those recommendations and instructed the health department and our local health networks to implement all those recommendations under the supervision, as well, of Dr John Brayley, the Chief Psychiatrist.

I am advised there has been very substantial progress made on implementing all four of the recommendations. In relation to recommendation 1, which stated that the pro forma document in Sunrise be amended to include a provision for recording the answer to a question as to whether the person is or has recently been under treatment by a psychiatrist or psychologist, and provision for recording that the psychiatrist or psychologist has been contacted to obtain relevant collateral information, Digital Health have added a section to the Sunrise EMR system in relation to treatment by a psychiatrist or psychologist. This has gone through IT production, and an end-user testing process has been implemented and made live on 31 January earlier this year. This system is now being used by public hospitals statewide.

The second recommendation is that SA Health should prepare and issue guidelines titled 'Care of individuals with mental health and substance abuse disorders in acute care settings'. These guidelines may be incorporated into the South Australian Guidelines for 'Working with a Suicidal Person'. A safety advice memo to LHN CEOs was sent to all services. This is still considered an interim response; however, the new suicide prevention pathways standard will address this, as this will be a mandatory requirement and a longer lasting way of incorporating changes into the local services.

Recommendation 3 stated that clinicians practising in hospital EDs should assess with a critical mind a patient's denials of current suicidal intent and should consider the possibility that denials of important and critical circumstances may be endangered by a desire to be discharged from hospital. In particular, denials of suicidal ideation should be evaluated against a patient's documented medical history and collateral history, including collateral history obtained from the person's treating psychiatrist or psychologist. This recommendation is also being addressed through suicide prevention training, that is addresses engagement with consumers and their family, obtaining an accurate understanding of risk and safety planning. This will be further embedded via the suicide prevention pathway standard.

Recommendation 4 was in relation to considering the feasibility of establishing a register of contact details for private psychiatrists to be available in public hospitals. It must be noted of course that the public health system cannot force private practitioners to provide their contact details and for them to be available around the clock. Despite our best efforts, there have been mixed reviews from private psychiatrists and therefore the participation of the registry will be voluntary, but of course we will be proceeding with our end and Digital Health has conducted a feasibility review on utilising various provider directories for recording of those practitioner details with a final update presented earlier this year. Digital Health are progressing incorporating the option for private practitioners to input those phone numbers and email addresses.