Bendigo Hospital's missed mental health check may have cost man his life
Coroner Ingrid Giles found a second mental health assessment may have prevented Mitchell Dean Johns' 2021 death at Bendigo Hospital.
Mitchell Dean Johns, 28, attempted suicide on May 27, 2021, and went to Bendigo Hospital. Staff found he didn't meet criteria for detention, despite his depression and past self-discharges.
A crisis clinician cleared him, but emergency staff thought it meant he could leave once treated. He left the hospital.
Later, a member of the public found him collapsed near the Golden Dragon Museum and brought him back. On this return, no second mental health check was done.
Coroner Ingrid Giles found this was a serious failure. Had a check been made, he likely would have been detained and treated until a psychiatrist assessed him.
Instead, he left again and died at home some hours later. The coroner made no findings against staff.
Instead, she found the hospital's systems failed to support integrated decision-making, and mental health and medical teams did not share key information about his condition.
Why it mattersA systemic gap in how hospitals share information between mental health and medical teams can be the difference between life and death for someone in crisis.
AustraliaBendigo Health must now revise policies to ensure clear guidance on who can make detention orders and require integration of medical and mental health planning for suicide attempt cases.
✓ Claims checked against the source. checked 14 h ago
