A Tasmanian coroner has recommended a review of staffing levels within a Royal Hobart Hospital psychiatry service, after an investigation into the death of a 23-year-old Howrah man more than four years ago.
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Edward Paisley Peck had been discharged from the hospital just hours before his death on August 10, 2015, after an emergency admission for a mental health crisis.
The investigation, by Coroner Olivia McTaggart, focused on whether Mr Peck should have been involuntarily admitted for treatment under the Mental Health Act - which hinged on psychiatrist Dr David Lang's assessment of whether Mr Peck had "decision-making capacity".
In the report released Thursday, Ms McTaggart found Dr Lang was aware of Mr Peck's risk of self-harm, but confident in his assessment the man possessed the capacity to make decisions about his treatment.
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With the "benefit of hindsight" Dr Lang accepted the case justified further information from Mr Peck's parents and Dr Ait Khelifa - a Hobart Clinic psychiatrist and addiction medicine specialist who had treated the man since December 2013 - though was "confident" his assessment would likely not have changed.
Ms McTaggart found it would have been "desirable" for Dr Lang to make contact with Dr Khelifa. Ultimately, she said his decision to discharge Mr Peck was "sound".
While providing evidence, Dr Lang indicated there was inadequate resourcing of the Consultation Liason Service - of which he was a part.
Ms McTaggart recommended that the Department of Health undertake a review of the staffing requirements for its "proper operation" at the hospital and provide further resources if needed.
She also praised Mr Peck's family for their role in the inquest. "Their collective efforts as a family in these extremely difficult circumstances have been commendable," she wrote.
On Thursday, State Growth Minister Michael Ferguson assured the recommendation would "absolutely" be implemented.
In a statement, a government spokesperson said: "Every death by suicide is a tragedy and the government extends our deepest condolences to Mr Peck's family". They added that a review of the Mental Health Act was accepting submissions.
Health and Community Services Union acting secretary Robbie Moore said members had previously raised concerns about "budget cuts and a lack of investment". He also extended his thoughts to Mr Peck's family.
Tasmanian Labor health spokesperson Sarah Lovell said the government should follow the recommendation while looking to boost treatment options outside emergency departments.
- Lifeline 13 11 14
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