Coroner recommends changes at Bendigo Health Care Group

Laycock family photo

Dean Laycock with members of his family in happier times

On Monday 22 December 2014 Her Honour Coroner Tregent delivered her findings in the inquest into the death of Dean Laycock, who died in while on leave from the Prevention and Recovery Care facility operated by the Bendigo Health Care Group (BHCG).

Coroner Tregent’s findings documented the following deficiencies in the care provided to Dean by BHCG:

  • A failure to communicate or consult with Dean’s family
  • A failure to undertake a mortality review
  • A failure to comply with the Mental Health Act 1986 and relevant Chief Psychiatrist’s Guidelines
  • A failure to adequately document Dean’s care, and
  • A breakdown in communication between BHCG staff

Dean’s family and Loddon Campaspe Community Legal Centre welcome the Inquest’s findings.

Although only public statutory bodies are mandated to respond to a Coroner’s recommendations, the family hopes that BHCG heeds the Coroner’s recommendations and assures the community that its current policies and procedures mitigate the potential for future tragedies.

Loddon Campaspe CLC, which represented the Laycock family, was pleased by the Coroner’s finding that the family could not be held in any way responsible for Dean’s death. CLC Lawyer Bonnie Renou: “BHCG’s strategy at the Inquest was, in part, to deflect the focus from its own deficiencies by calling into question the responses by Dean’s family to his agitated state following his release on leave and prior to his taking his life. Coroner Tregent rejected this line of attack.”

Dean’s father Peter Laycock said of BHCG: “their strategy was to deflect the blame on us, now the Coroner has said that’s not right.”

Bonnie Renou: “Coroner Tregent acknowledges that BHCG has made improvements to practice and procedure subsequent to Dean’s death, but we do not believe they have gone far enough. For example, verbal patient handovers are a manifestly inadequate substitute for comprehensive, up-to-date case notes.”

The key facts of the matter are that in 2009 Dean Laycock, then 24, from Heathcote, was a patient at the Prevention and Recovery Care facility (PARC) operated by the Bendigo Health Care Group (BHCG). Dean was diagnosed with schizophrenia and was identified as having an intellectual disability. Prior to his discharge to PARC, Dean was an involuntary patient at the Alexander Bayne Centre, also managed by BHCG. Dean was discharged to PARC to assist his transition to independent living. Prior to his discharge to PARC, Dean was told by his treating psychiatrist at the Alexander Bayne Centre that he would be granted four days leave over Christmas. Dean was excited at this prospect and his family was happy and able to care for him.

On the cusp of his release a decision was made at a Clinical Team Meeting at PARC to reduce Dean’s leave to two days. This meeting was chaired by a consultant psychiatrist who had neither met Dean nor consulted with his treating psychiatrist nor read his case notes. The reduction in leave was made on the basis of an unsubstantiated and undocumented assertion by a PARC staff member that Dean’s mother was unable to care for Dean for the full four days.

The assertion did not go unchallenged, but the team member who challenged this decision was overruled and delegated responsibility for breaking the news to Dean and his mother when she came to collect him later that afternoon. Dean was visibly upset at this news but the late notice and the failure to consult with the family thwarted a full and proper risk assessment. That night Dean took his life at his mother’s house.

For more information, please see our Summary of the Coroner’s key findings, recommendation and references.


For further media comment

Bonnie Renou, Lawyer, Loddon Campaspe Community Legal Centre, (03) 5444 4364 or 0419 108 394.



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