Tasmania's coroner has found that a man had been given the proper treatment and appropriately discharged from hospital, despite killing his wife and then taking his own life a few weeks later.
Coroner Olivia McTaggart found 62-year-old John Evans was in the grip of a psychotic delusion when he murdered his wife of 40 years, Jillian, inside their home in the Launceston suburb of Riverside in September 2013.
Mr Evans had been treated for mental health issues since the 1970s, which worsened after the couple's only child died in a car crash in 1990.
From May 2013, Mr Evans had been presenting regularly to his general practitioners with anxiety, a deteriorating mental state and emerging psychosis, which was manifesting in delusions relating to toxic effects of the smoking from his neighbour's chimney.
But Coroner McTaggart said the detection of an emerging psychosis was a very difficult diagnosis for his treating medical practitioners to make.
On July 17, 2013, Mr Evans went to the Launceston General Hospital (LGH) after a severe downturn in his mental health.
Coroner McTaggart said he was correctly assessed and diagnosed by Dr Been as being a major depressive episode with psychotic features, and was involuntarily admitted for treatment.
After two days that order was discharged, and Mr Evans transferred as a voluntary patient to St Luke's private hospital.
He was discharged after a week and just over a month later murdered his wife and took his own life at home.
Coroner McTaggart found the treatment of Mr Evans by his doctor and in hospital was reasonable, and his discharge both from the LGH and St Luke's appropriate.
Coroner McTaggart said the murder-suicide had been unforeseeable and resulted from a sudden unexpected downturn in his mental illness.
But she found there were deficits in the completion of important LGH documentation pertaining to Mr Evans' mental state and the order, and deficits in the transfer of information to St Luke's, his doctor and psychiatrist..
She recommended the LGH improve its paperwork processes to ensure that other hospitals and treating medical professionals were fully informed in a timely manner of ant treatment and admissions for mental health issues.
