FINDINGS INTO THE DEATH OF MIJO GALINEC

In the Coroners Court of the Australian Capital Territory, the matter concerning the findings into the death of Mijo Galin, a 27-year-old patient, was heard. The inquest sought to establish the circumstances surrounding Mijo's death, which occurred while he was an inpatient at the Calvary Public Hospital. The court examined the hospital's policies and procedures, particularly those related to the management of patients experiencing psychiatric or psychological issues in an open ward, as well as the adequacy of clinical handover processes. The family of Mijo Galin questioned whether there were systemic failings that contributed to his death.

The primary legal issue was whether there were any breaches of policy or procedural failures by the hospital that could be considered contributory factors in Mijo's death. The court examined whether the hospital's absconding patient policy and the clinical handover process complied with statutory obligations under the Coroners Act 1997 (ACT) and other relevant guidelines. It also considered whether these policies and procedures were adequately implemented and monitored to ensure patient safety.

The court found that the hospital's absconding patient policy was not adequately implemented, leading to a failure to prevent Mijo from leaving the ward unsupervised. Additionally, there was a breakdown in the clinical handover process, resulting in critical information being overlooked. These failures were identified as contributory factors in Mijo's death. The coroner emphasised the importance of robust policies and procedures, as well as their proper implementation, in preventing such tragedies in the future.

The coroner recommended several measures to improve patient safety, including a review and strengthening of the absconding patient policy, enhanced training for staff on clinical handover procedures, and better monitoring of policy compliance. The coroner also called for ongoing evaluation of these recommendations to ensure they are effectively implemented and lead to meaningful improvements in patient care.