A mental health review prompted by a patient allegedly murdering a woman and attacking another shortly after release has recommended changes at a major hospital.
Shaun Michael Dunk was being treated for a mental health condition at the Royal Adelaide Hospital before a clinical decision resulted in him being released into the community on December 18, 2023.
Two days later, he allegedly wandered into a real estate agent office and killed one woman and seriously injured another in a random knife attack.
Dunk was charged with the murder of Julie Seed, 38, and the attempted murder of her colleague Susan Scardigno, 50 at their work in the Adelaide suburb of Plympton.
The incident triggered a review into Dunk's mental health treatment which was publicly released on Saturday.
The review found there was no evidence the decisions made by any individual clinicians had fallen below an acceptable standard.
But it highlighted systemic issues including the emergency department model of care not being designed or resourced for effective mental health treatment.
Dunk had been admitted to the Royal Adelaide Hospital on a compulsory inpatient treatment order and was released on December 18.
He spent the following night at the Urgent Mental Health Care Centre in the CBD, a voluntary walk-in service run by clinicians and people with lived experience of mental illness.
The report's recommendations include establishing a shared process between Royal Adelaide Hospital and the urgent care centre to flag frequent attenders and develop an agreed management plan.
Other recommendations include a review into mental health staffing at Royal Adelaide and the role of security guards for mental health patients.
The review also called for a review of risk assessment policies and an audit of the management of patients presenting to the Royal Adelaide emergency department under the influence of illicit substances.
SA Health Minister Chris Picton said the government will implement all recommendations in the report.
"We have given the first opportunity to the families to discuss the findings and recommendations, and are now immediately releasing them publicly and to our clinical teams," he said.
Chief psychiatrist John Brayley and SA Health chief executive Dr Robyn Lawrence will oversee their implementation.
Dr Brayley said the recommendations come after a string of recent violent events that have "distressed our entire community".
"Both the agreed system changes and future law changes aim to improve the care for individuals, enhance community safety and support staff," he said.
Lifeline 13 11 14
beyondblue 1300 22 4636
