Deceased
Anthony Leigh Bearham, Nicola Joy Fisher, Christine Belle Douch, Ken Alexander Lucas
Coroner
Coroner Hunter
Date of death
2015-2016
Finding date
2021-03-04
Cause of death
Bearham: hypoxic brain injury from hanging; Fisher: asphyxiation from hanging by dressing gown belt; Douch: haemothorax and blunt chest injuries from fall from height; Lucas: global cerebral hypoxia from hanging
AI-generated summary
Four inpatient suicides occurred at The Canberra Hospital mental health units between January 2015 and November 2016: three by hanging and one by jumping. The coroner found systemic failures including inadequate ligature risk mitigation, poor observation procedures, failure to properly search for dangerous items, inadequate staff training, and communication failures between clinical staff and investigators. Key issues included use of non-ligature-proof door handles, failure to detect a dressing gown belt used as ligature, missed ARC observation changes, and staff reluctance to cooperate with police investigations. Recommendations addressed training, policies, technological safeguards, and accountability systems.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
CORONERS COURT OF THE AUSTRALIAN CAPITAL TERRITORY Case Title: Inquest into the deaths of ANTHONY LEIGH BEARHAM, NICOLA JOY FISHER, CHRISTINE BELLE DOUCH and
KEN ALEXANDER LUCAS Citation: [2021] ACTCD 1 Decision Date: 04 March 2021 Before: Coroner Hunter Decision: [1226] – [1229] Catchwords: CORONIAL LAW – MENTAL HEALTH – 4 Inpatient Deaths by suicide at The Canberra Hospital Campus – ligature risks – hospital policy and procedure – recommendations Briginshaw v Briginshaw (1938) 60 CLR 336 Cases cited: Harmsworth v The State Coroner [1989] VR 989 Lucas-Smith v Ors SC 117 of 2007 March v E & MH Stramare Pty Ltd [1991] 17 CLR 506 Onuma v The Coroner’s Court of South Australia [2001] SASC R v Doogan; Ex Parte Lucas Smith & Ors [2005] ACTSC 74 Saraf v Johns [2008] SASC 166(18) The Queen v Coroner Maria Doogan; ex parte Peter Lucas-Smith & Ors [2005] ACTSC 74 WRB Transport v Chivell [1998] SASC 7002 Legislation cited: Coroners Act 1997 (ACT).
Representation: Ms S Baker-Goldsmith and Mr M Kamarul appearing as Counsel Assisting the Coroner.
Ms V Thomas of Counsel appearing as Counsel for the Territory, instructed by the ACT Government Solicitor.
Mr H McCay appearing as Counsel for Doctor Pate.
Mr J Johnson appearing as Counsel for Doctor Mynit.
Ms K Katavic of Counsel appearing for RN Nissen.
Mr A Freer appearing as Counsel for RN Eldridge.
File Number(s): CD 8 of 2015 CD 61 of 2015 CD 164 of 2016 CD 281 of 2016
CORONER HUNTER Introduction
There were several deaths by suicide between January 2015 and December 2016 at the Adult Mental Health Unit on The Canberra Hospital Campus. I was asked to conduct Inquests into the deaths of four in-patients at The Canberra Hospital Campus. Three of those deaths were by hanging and one was by jumping from an elevated floor to the ground floor of The Canberra Hospital.
All four deceased had been previously treated for their mental illness. All four died within a few days of admission to either the Medical Assessment and Planning Unit (MAPU), Mental Health Assessment Unit (MHAU) or the Adult Mental Health Unit (AMHU).
Two different mechanism for the three hanging deaths were used. One mechanism was the tying of a ligature to the outside door handle (described as a non-ligature point handle) and slinging the ligature over the other side of the door to be used as a hanging point. The other mechanism was to tie a big knot in the ligature and sling it over the door wedging it between the door jam and the door to use as a hanging point.
The inquest was held in two phases. The first phase comprised of hearing the circumstances of each individual death. The second phase arose out of issues raised in relation to protocols within the hospital. This phase focused on whether those protocols were followed in the first instance and secondly whether they were adequate in the circumstances.
In the first phase I examined the circumstances of each individual death. In the second phase I heard evidence from experts in relation to several matters. These matters involved protocols, review of the mechanism used by the deceased to suicide by hanging, review and changes to protocols since the deaths and reconfiguring of the accommodation in the Adult Mental Health Unit since the deaths.
In the first phase I heard evidence of the circumstances surrounding all four deaths. I also heard from the families of the deceased in relation to the prior history of mental illness suffered by their loved ones as well as their expressions of grief. The Court was deeply moved by the grief expressed by the families as well as the frustration and pain identified by the families over the loss of their loved ones whilst in the care of ACT Health.
The Court took evidence over eleven Hearing days throughout 2018. The Court received numerous volumes of material which included statement from relevant witnesses, the Coroner’s investigator, medical records, expert reports and hospital protocols in relation to the four inquests. Two site views were conducted as well as an informal examination of the area where Ms Douch died.
The facilities, particularly in relation to ligature points, were examined at length. The hospital protocols were also examined, particularly in relation to patient observations, handovers and nursing duties in general.
I have already made preliminary findings as to the manner and cause of each of the deceased.
Preliminary Matters Jurisdiction
(a) “Although there were a number of changes to the Coroners Act 1997 (ACT) (“the Act”) between January 2015 when Mr Bearham died and November 2016 when Mr Lucas died, the basis of the jurisdiction in respect of each death remained substantively the same:
(i) [for Mr Bearham & Ms Fisher] a Coroner is required to hold an inquest into the manner and cause of death of a person who dies, or is suspected to have died, a sudden death the cause of which is unknown: see section 13(1(c) of the Act as it was in force at the time; and (ii) [for Ms Douch & Mr Lucas] a Coroner is required to hold an inquest into the manner and cause of death of a person who dies violently, or unnaturally, in unknown circumstances: see section 13(1)(a) of the Act as it was in force at the time.
(b) The scope of enquiry available to a Coroner is set out in the decision of Onuma v The Coroner’s Court of South Australia [2001] SASC 218, a case in which the Court considered the scope of the Coroner’s power under the Coroners Act 2003 (SA) and applied WRB Transport v Chivell [1998] SASC 7002. The relevant phrase under consideration was “cause and circumstances”; this compares favourably to the phase “manner and cause” in the ACT Act. In Chivell Lander J (with whom both Prior and Mullighan JJ agreed) said with regard to the meaning of the word “cause”: “Clearly enough the cause and the circumstances must be two different things if it was otherwise there would be no reason for Parliament to have included both words. ... The cause of a person’s death may be understood as the legal cause. In determining those events which may be said to give rise to the cause of the death, the coroner is not limited by concepts such as direct cause nor is the coroner limited to a cause which is reasonably foreseeable. The cause of a person’s death in respect of the coroner’s jurisdiction is a question of fact which, like causation in the common law must be determined by applying common sense to the facts of each particular case.”
(c) All four persons died at their own hand or as a consequence of a self-harm attempt whilst receiving inpatient treatment at The Canberra Hospital (TCH). All had had some engagement with mental health services, and all but Ms Douch were inpatients in specialist mental health wards. Ms Douch was being treated on a general medical ward for medical complications of pharmaceutical overdose as a self-harm attempt.
Required Findings
(d) Under subsection 52(1) of the Act, a Coroner holding an inquest must find, if possible:
(i) the identity of the deceased; and
(ii) when and where the death happened; and (iii) the manner and cause of death; … The Coroner must record her findings in writing: s 52(3).
(e) Further, subsection 52(4) of the Act provides as follows: The coroner, in the coroner’s findings—
(f) possible:
(i) must— i. state whether a matter of public safety is found to arise in connection with the inquest or inquiry; and ii. if a matter of public safety is found to arise—comment on the matter; and (ii) may comment on any matter about the administration of justice connected with the inquest or inquiry.
(g) In making findings, the Coroner is to have regard to the principle laid down in in Briginshaw v Briginshaw (1938) 60 CLR 336 as stated by Dixon J at 361-2: “The truth is that, when the law requires the proof of any fact, the tribunal must feel an actual persuasion of its occurrence or existence before it can be found.
... The seriousness of an allegation made, the inherent unlikelihood of an occurrence of a given description, or the gravity of the consequences flowing from a particular finding are considerations which must affect the answer to the question whether the issue has been proved to the reasonable satisfaction of the tribunal.”
(h) In R v Doogan; Ex Parte Lucas Smith & Ors [2005] ACTSC 74 (5 August 2005) the Full Court of the Supreme Court comprising Higgins CJ, Crispin and Bennett JJ stated at [12] in relation to the nature of the Coroner’s inquiry: “The task of a coroner is not to determine whether anyone is entitled to some legal remedy, is liable to another or is guilty of an offence. The Coroner’s task is to inquire into the matters specified in the relevant section of the Coroners Act 1997 and make, if possible, the required findings and any comments that may be appropriate.”
(i) In Harmsworth v The State Coroner [1989] VR 989 at 997, Nathan J discussed the ambit of the Coroner’s power to comment as follows: “The power to comment arises as a consequence of the obligation to make findings … It is not free ranging. It must be comment ‘on any matter connected with the death.’ The powers to comment and also to make recommendations … are inextricably connected with, but not independent of the power to enquire into a death or fire for the purposes of making findings. They are not separate or distinct sources of power enabling a coroner to enquire for the sole or dominant reason of making comment or recommendation. It arises as a consequence of the exercise of a coroner’s prime function that is to make ‘findings.’ “
158 ACTR 1 (R v Doogan (No. 2)) Where the Court in relation to manner and cause concluded: “that the range of matters falling within the scope of inquiry, whilst not open-ended, are those that could be considered relevant to determining the cause and origin of the fire causing the damage.” His Honour then went on to say: All intervening or contributing events may be considered (see R v Doogan (No. 2) [20]).
And at [18] The limiting factor is that of relevance to the issue of cause and origin of the fire process and progress.
His Honour then went on to give an example at [19- 20].
“An example of that limitation may be found in the evidence given by the plaintiffs of attempts to obtain government funding for the purposes of community education programs (plaintiffs’ submission [28]). Whilst the Coroner might well comment that lack of such programs contributed to the extent of fire damage, it would be inappropriate for the Coroner to enquire into the reasons for the Government or the Parliament declining funding for such programs.
It may be difficult in some instances to draw a line between relevant evidence and that which is too remote from the proper scope of the inquiry. At [26] in R v Doogan (No. 2) some examples of that difficulty are provided. It may also be necessary for a Coroner to receive evidence in order to determine if it is relevant to or falls in or out of the proper scope of the inquiry.”
Section 55
Subsection 55(1) of the Act provides as follows: A coroner must not include in a finding or report under this Act (including an annual report) a comment adverse to a person identifiable from the finding or report unless the coroner has, making the finding or report, taken all reasonable steps to give to the person a copy of the proposed comment and a written notice advising the person that, within a specified period (being not more than 28 days and not less than 14 days after the date of the notice), the person may— a. make a submission to the coroner in relation to the proposed comment; b. or give to the coroner a written statement in relation to it.
In considering and/or making adverse findings the Briginshaw principles are particularly relevant.
I am also required to bring an unbiased mind to determine the facts according to the evidence, the facts proven in this inquest. In doing so, I should bring to bear my common sense and experience.
Manner and Cause of Death – Phase I Anthony Leigh Robert Bearham
History
Mr Bearham was born in Werribee, Victoria. It appeared he suffered from, and was diagnosed with, attention deficit disorder and attention deficit hyperactivity disorder. Mr Bearham was, it appeared, chronically depressed and spoke often about suicide. One reason he gave was to be close to his brother who had died of sudden infant death syndrome. Mr Bearham regularly self-harmed and had been treated in hospital on several occasions for non-life-threatening cuts to his forearms and thighs. (Self-harm)
Mr Bearham was diagnosed with paranoid schizophrenia at around age 17, whilst in juvenile detention in South Australia. Mr Bearham had a significant criminal history for his age. On 25 December 2014, Mr Bearham was found wandering the streets in a delusional state and was conveyed by ambulance to The Canberra Hospital where he was admitted on an Emergency Detention Order following psychiatric review. He was an involuntary patient and was admitted to the Adult Mental Health Unit following psychiatric review. The involuntary order was discontinued after three days in AMHU after review by Dr Richard Gray. Mr Bearham remained on the ward as a voluntary patient.
On 28 and 29 December 2014, Mr Bearham took unaccompanied leave from the unit and returned within the allotted time. On 30 December, the day of his birthday, he was late returning to the Ward after being allowed unaccompanied leave.
On 4 January 2015 at approximately 22:00 hours Mr Bearham was seen in the games room sitting in the dark whilst using his phone. He was asked by RNs Duffy and PrestonBond to leave the room as they were locking it. He moved to the Social Spine (an open space for patients to mingle, in the form of a corridor between wings of patient bedrooms) and was listening to his phone. At approximately 22:40 hours, Mr Bearham was seen pacing the ward and appeared anxious. The nursing staff gave him his sedative medication and told him to go to bed. At approximately 23:00 hours, staff observed that Mr Bearham was not in his room. The nursing staff did not consider this unusual as patients are free to roam the ward. Later, Mr Bearham was observed by RN Diaz making a drink near the TV lounge in the Social Spine. At approximately 23:25 hours RN Duffy commenced her observation rounds starting at the Orange Wing. When RN Duffy arrived at the Green Wing to continue her observations, she observed that Mr Bearham was not in his room. RN Duffy observed a piece of paper left on his bed with words written about the meaning of life on it. RN Duffy went looking for Mr Bearham and located him in the Social Spine outside a bathroom. RN Duffy observed that he was fully suspended by the neck by a hospital blanket which had been passed over a door. She was unsure if it was tied off on the opposite side to a door handle. Ms Duffy
had no clear recollection of how the ligature was affixed to the door. A code black was called followed by a code blue.
A resuscitation team was sent to the Adult Mental Health Unit along with ACT Ambulance Services. Resuscitation processes were administered to Mr Bearham successfully and he was transferred to the Intensive Care Unit where he was placed on life support.
On 6 January 2015, Police attended the Adult Mental Health Unit but were denied access to the incident scene. Police were told it was because staff with the authority to admit the Police were not available until the next morning. Police attended again on 7 January and were shown to the scene at the bathroom in the Social Spine. AFP forensics services examined the area including the bathroom door used by Mr Bearham to hang himself.
It was noted that the door handle used by Mr Bearham to attach the hospital sheet had been replaced with a different type of handle which was recessed. The original handle which had been removed however was shown to Police. The handle was a straight lever handle. Police ultimately determined that there was no third-party involvement or suspicious circumstances involved in his death.
Toxicology results from testing taken in intensive care indicated a positive result for methamphetamine. At 15:41 hours on 6 January 2015 scans revealed no viable brain activity and Mr Bearham was pronounced legally brain dead by Dr Kumar who then notified Police. Mr Bearham was formally identified by his mother. Police were notified.
They attended the Intensive Care Unit and made observations of markings on his neck which were consistent with hanging. Police also made observations of scarring that appeared to be the result of self-harming.
Nicola Joy Fisher History
Ms Fisher was found hanging by a dressing gown belt, wedged on top of the ensuite bathroom door in room 5 of the MHAU, at The Canberra Hospital Garran. Her death was self-inflicted. The Chief Coroner made interim findings of Ms Fisher’s death on the 11th of February 2016. The Chief Coroner found that the interim cause of death was hanging which was self-inflicted.
History
She had four of her own children aged between 21 and 23 years. There was a history of sexual abuse as a child which led to long-term unhappiness and depression. That abuse was perpetrated by a parish priest named Patrick Cusack. The Catholic Church was the institution which allowed this behaviour to occur and Cusack had “unfettered access to children” at a time when the Church had knowledge of his proclivity.
Ms Fisher was treated for her mental health issues by her GP. Her GP had prescribed medication for her illness. Ms Fisher’s family stated that she regularly spoke to them about committing suicide. At the time of and prior to her death she had not been regularly seeing any mental health specialist. Ms Fisher had been treated years earlier in the ACT mental health system. (In the years 2006 to 2007).
On the morning of 17 March 2015 Ms Fisher became involved in an altercation with one of her children. Her family attended her residence, but she refused to engage with them and became avoidant. Her family called the ACT Mental Health Crisis Team (CATT) at approximately 14:15 hours. This was due to Ms Fisher’s drowsiness and concerns that she may have taken an overdose of her medication. The family also found a note written by her on a table and they informed the Crisis Team of this at approximately 15:22 hours. The note said: “constantly inflicting damage on the kids versus one big trauma. Decided one big trauma easier to bear/repair, than constantly failing trying to minimise the damage. In the end better for them. Tried not to inflict damage, but don’t seem to be able not to.
Every action leaves damage. So much better if they are rescued from that. Best action is to let them free.”
The Crisis Team arrived at approximately 17:00 hours and spoke with Ms Fisher. They observed that Ms Fisher had cut herself on her left forearm. An ambulance was called, and she was taken to The Canberra Hospital. At the time she was taken to The Canberra Hospital she was wearing a dressing gown. Ms Fisher was admitted to the Emergency Department at 18.07 hours for the purposes of examining her lacerated arm. A Doctor in the Emergency Department sutured her arm laceration.
A suicide risk assessment was also conducted by a junior doctor in the Emergency Department however, Ms Fisher refused formal assessment by Consultant psychiatrist Dr Gupta. Despite this Dr Gupta formed the view that it was not necessary for her to be involuntarily detained. Dr Gupta considered that another doctor might try to assess her
the next morning after she had some sleep. At approximately 06.00 hours Ms Fisher was admitted to the MHAU as a voluntary patient. Ultimately, she was moved to room 5 later in the day.
The allocated room was at the end of the corridor and had an ensuite bathroom attached to it. The ensuite door had a special purpose swinging door for ease of access, if locked and was able to be opened by staff if locked from the inside.
At approximately 14:00 hours on 18 March 2015 Consultant psychiatrist Dr Roderigo assessed Ms Fisher. Initially it was thought that Ms Fisher could be discharged home as it appeared, she was suffering a situational crisis. However, Dr Roderigo then diagnosed her with severe depression with suicidal intent and considered that she would not be safe at home. Dr Roderigo, using the clinical risk assessment scale considered her to be low to medium risk of suicide.
As a result of this determination Dr Roderigo ordered that Ms Fisher be observed every 30 minutes to ensure her safety. The treatment plan included that Ms Fisher was to be admitted to the Adult Mental Health unit as soon as a bed became available.
Ms Fisher’s daughter Freya was asked to provide information in relation to Ms Fisher’s mental health history to treating doctors. Freya saw that her mother still had the blue dressing gown that she was in when she was taken to hospital. Later that day at approximately 19:59 hours RN Dolton reviewed Ms Fisher and observed that she had spent most of the day in bed and tried to engage with her. Ms Fisher drank some fluids but refused all meals and most of her medication.
On 19 March 2015, Ms Fisher’s family attended to visit her. They brought a new dressing gown and slippers for her. However, she refused to see her family and those items were left with the staff. It transpired that the dressing gown had a belt on it. These items were left with the nursing staff. Those items were exhibited before me.
During the rest of the day RNs tried to engage with Ms Fisher with little success and she continued to refuse fluids and food.
Ms Fisher did not receive any mental health treatment save for her continuation of medication which she refused to take at times. Ms Fisher was not formally reassessed by any Consultant psychiatrist prior to her death.
At approximately 07:00 hours on 20 March 2015, Ms Fisher’s care was handed to a new team of RNs comprising RNs Robson, Matsika and Lanfranchi. RN Matsika was allocated to look after Ms Fisher.
At approximately 07:30 hours, RN Matsika attended on Ms Fisher due to concerns she had not consumed food or water the previous day. RN Matsika formed the view that she was withdrawn and not engaging and whilst he gave her the prescribed medications, he suspected that she did not consume the medication but instead hid it.
RN Matsika changed Ms Fisher’s bed linen to check whether she had hidden them in the bed clothes but did not find any medication secreted in that area. At approximately 08:00 hours, RN Matsika took her observations including blood pressure.
RN Robson was tasked to undertake ARC checks on Ms Fisher that day. The observations from 07:00 hours were to be made every half hour on the half-hour and hour mark. RN Robson indicated on his observation chart that Ms Fisher had been resting in bed.
At approximately 08:40 hours, Dr Wood reviewed Ms Fisher. Dr Wood made contemporaneous notes that Ms Fisher was diagnosed as suffering from mild dehydration and Dr Wood prescribed her fluids as a first line of treatment. Dr Woods then left her room to obtain some water and juice for her. When Dr Wood returned, she saw Ms Fisher entering the bathroom and closing the door. Dr Wood left the bottles without any further conversation with Ms Fisher. At 09:00 hours when RN Robson conducted his check of Ms Fisher, he did not see her in her room.
RN Matsika gave evidence that he conducted a check of Ms Fisher at 09:15 hours and saw her sitting on the couch in her room. At approximately 09:35 hours, RN Matsika checked on Ms Fisher and saw that her bathroom door was closed and locked. RN Matsika knocked on the door and received no response. He went back to the administrative office and asked Ms Sealey to attend with him.
They walked back to room 5 and RN Matsika began to open the bathroom door with the screwdriver. As they were attempting to open the door it was observed by Ms Seeley that there was something coloured and protruding at the top of the door. When the door was open Ms Fisher fell onto the floor and partway into the room. Ms Fisher had a ligature formed from her dressing gown belt around her neck. Her lips and face were blue.
RN Matsika depressed his duress alarm and attempted to hold the ligature from the front of Ms Fisher’s neck. Miss Seeley ran back to depress the code blue call to generate a medical emergency call out.
Resuscitation processes were conducted. Dr Cole attended from the Emergency Department with other medical staff. Dr Cole asked RN Matsika about the circumstances in which Ms Fisher had been found. Scissors were located to cut the ligature from her neck. Resuscitation efforts were conducted and after some time Dr Cole considered that the likelihood of recovery was negligible. He pronounced life extinct at 09:43 hours. Dr Cole then directed that Ms Fisher be moved from the floor onto the bed.
At 10:17 hours Dr Cole contacted Police to report the death to the coroner. Police and the criminal investigation members arrived, and a crime scene investigation was undertaken. Police undertook recorded conversations with Dr Cole and a Wardsman Mr Archer. Detective Senior Constable Best was advised that no other staff from ACT Health would speak or provide statements to Police that day. Staff including RN Matsika had agreed to speak with Police without providing formal statements.
Miss Fisher was identified by her sister Rosemary. Police found no evidence of any third-party involvement or suspicious circumstances in her death.
An issue arose in the inquest in relation to whether Ms Fisher had been seen between the hours of 08.40 when Dr Wood saw Ms Fisher going to the bathroom and 09.35 when RN Matsika found the bathroom door locked.
Christine Belle Douch
History
Ms Douch was born in Bega, New South Wales and married her husband in 1973. She had four children and was a home maker. The family lived in Bombala for most of their lives. Ms Douch was a very active and social member of the community enjoying squash, tennis, darts and pool and was a very keen gardener. She also enjoyed fishing, painting and drawing.
Ms Douch was a very keen golfer and was the champion of the local club. Health issues arose for Ms Douch which curtailed her physical activities significantly. The conditions she suffered from cause her significant pain. Medication and surgical intervention had limited success in easing her symptoms. The pain was so great and relief so inadequate that it led to her mental health declining. Ms Douch attempted suicide by overdosing on her medications between 1996 and 1997. Ms Douch was located by her family and taken to hospital for treatment.
Ms Douch suffered from rheumatoid arthritis, systemic lupus erythematosus (SLE), gastro-oesophageal reflux disorder, fibromyalgia, migraines, back pain, chest and knee pain and narcolepsy. These were long-term illnesses which were treated by her general practitioner Dr Pate as well as several other specialists including rheumatologists, immunologists, orthopaedic surgeons, cardiologists, gastroenterologists and neurosurgeons. She also attended various pain specialists over the years. Her conditions were severe and chronic.
Over the years, Ms Douch received treatment for her mental health issues. However, the underlying problem of chronic intractable pain continued. Given the pain was the basis of her mental illness she did not continue with mental health counselling.
It appeared that Ms Douch turned to cannabis as self-medication for her pain. It appears that this had some effect. Cannabis was difficult for her to obtain and she eventually ceased consuming it approximately one month prior to her death.
Ms Douch commenced a trial of a new medication called Belimumab (BCT) at The Canberra Hospital. This was for her systemic lupus erythematosus. The trial was a randomised double-blind placebo controlled 22-week trial.
Known serious side effects of the trial drug Belimumab included mental health issues such as suicide, depression, trouble sleeping and anxiety. It is known that these conditions are also common in people who suffer from SLE. Given that circumstance Ms Douch was subjected to the Columbia Suicide Severity Rating Scale each time she presented for treatment. Ms Douch was also referred to Dr Kumar, a Consultant psychiatrist, for psychiatric assessment. It was Dr Kumar’s view that following an assessment using the scale the treatment did not pose a significant risk of suicide for Ms Douch and opined that she could proceed with treatment. It was Dr Kumar’s view
that the cause of her depression and anxiety was her severe pain. Despite this Dr Kumar indicated that if her distress worsened, she should be referred back to him.
During the trial of Belimumab, Ms Douch complained of suicidal ideation and this presented itself consistently up until week 20 of the trial. Ms Douch had feelings of selfharming on a daily basis and those feelings were persistent.
On 11 April 2016, Ms Douch presented for an unscheduled visit with the BCT staff. Ms Douch disclosed that she wanted to go to sleep and not wake up. This change was considered to be as a result of a change to her pain medication rather than the trial medication and she was referred back to Dr Kumar. Dr Kumar amended her medication to include Endep and he made a recommendation that she receive support from the Crisis Assessment and Treatment Team (CATT).
It is not known whether Ms Douch received the trial drug or the placebo. Professor Matthew Cook opined that due to the half-life of the drug, had deceased been receiving it and not the placebo, the amount in her body at the time of her death would have been negligible.
In June 2016, Ms Douch referred herself to her general practice and saw Dr Emma Cunningham. She stated that she had contemplated self-harm and had a plan to take medications but was interrupted by her grandson. On 28 June 2016, Mr Douch woke to hear his wife gurgling and was unconscious in bed beside him. An ambulance was called, and Ms Douch was taken to Bombala hospital. Her daughter was asked by the medical staff which medication her mother had taken and as she was unsure, she was told to go back to the home to see if she could find what medication had been consumed.
On arrival at the home, Ms Douch’s daughter Joy found a suicide note and upon further searching found a very large quantity of various prescription medications both used and unused. Joy left the note at the residence but took the medication she had found to the hospital. Joy informed staff including Dr Myint about the note as well as the medications she had located. Dr Myint and the hospital staff arranged for her to be transferred to The Canberra Hospital. Ms Douch was admitted to the Medical Assessment and Planning Unit (MAPU) of The Canberra Hospital.
Mr Douch advised the hospital staff that a suicide note had been found and that Ms Douch had previously attempted suicide years ago. Ms Douch advised medical staff that she had only overdosed on the methadone because of her pain as she was not feeling well, and she was sad. As a result of that assessment she was deemed suitable for admission to the MAPU. Ms Douch was medically assessed as at high risk of suicide. As a result of that assessment observations were set at every 30 minutes.
The MAPU is a short stay unit with patients staying on the unit ideally less than 72 hours for in-patient medical management. The initial status for Ms Douch was to manage the kidney and liver impairment diagnosed as a result of her overdose. Much of her medication was ceased other than some limited pain medication, as well as medication for cholesterol and antibiotics.
Ms Douch underwent a psychiatric assessment with Dr Regna. The assessment also included family members Joy and Mervyn. Dr Regna noted that the overdose was as a result of pain rather than suicide. Ms Douch further advised that she had no thoughts
of self-harm or suicidal ideation. It was thought by her family members that this was the case as well.
As a result of that assessment the one-on-one observations of Ms Douch were ceased, and she was referred back to Cooma Mental Health Services. Ms Douch declined to attend that service.
On 2 July 2016, a further mental health assessment was requested but was not completed. It is not known why this assessment was required and it appears that as a result of the findings of Dr Regna none was undertaken.
Ms Douch was further assessed by Dr Kelly from the Rheumatology Department. Dr Kelly reviewed her medications and ceased several of her medications, given she had some liver and kidney failure. Her liver and kidney function improved, and she displayed no signs of infection.
The Drug and Alcohol Treatment Team reviewed Ms Douch and the team raised concerns in relation to the management of her condition and her long-term opiate management. There was also a concern that she may be stockpiling these medications.
A plan was designed to have her medications placed into a Webster Pack to minimise the risk of stockpiling.
The social workers also reviewed Ms Douch, noting that her overdose was as a result of pain issues rather than mental health issues. Ms Douch complained of her pain becoming worse and was referred to Dr Soh from the Drug and Alcohol Team. Dr Soh assessed Ms Douch and determined that she was not opioid addicted and therefore declined to prescribe Suboxone.
On 5 July 2016, Ms Douch asked to speak to RN Karia because she had something to tell her. RN Karia spoke to Ms Douch over a period of an hour. During that time Ms Douch told her why she took the overdose of her medications. Ms Douch told her that she was sick of the pain and just wanted to end it. Ms Douch, during the course of that conversation indicated that she would not go through with this plan because of her fondness for her grandson. Ms Douch asked RN Karia not to disclose the conversation.
RN Karia did disclose in her notes and in conversation with her colleagues about the conversation she had with Ms Douch but did not disclose that she had been told that Ms Douch had planned her suicide by overdose whilst her husband was watching the television. Despite this information being recorded no further assessment of Ms Douch was undertaken.
That same day nursing staff noted Ms Douch was distressed and Dr Soh from the Drug and Alcohol Team reviewed her and considered her to be in withdrawal. Dr Soh prescribed Targin a long acting opiate as well as Endone a short-acting opiate. Shortly thereafter, Ms Douch complained of severe pain including chest pain headaches and leg pain. She described her level of pain as 10 out of 10.
Ms Douch was anxious about her transfer to the Cooma hospital which was to take place that afternoon. After some consideration it was decided not to transfer her to the Cooma hospital, and she was prescribed Oxycodone to manage her pain.
At approximately 20:50hrs that evening Ms Douch was in agonising pain and was screaming and believed she could not cope with the pain overnight. Ms Douch asked
RN Karia if she could go for a walk. At the time she was with her husband and RN Karia agreed for her to be able to go for a walk.
At approximately 21:00 hrs Ms Douch walked past the RN’s station clutching a heat pack to her chest. Ms Douch apologised to staff for her behaviour earlier and then continue to walk past them. No staff noticed that she had left the ward. At 21.35 a wardsman observed her walking on level 3 near the balcony where it overlooks the atrium in the foyer on level 2. The wardsman observed her to be carrying a heat pack to her chest. Ms Douch was alone, and nothing seemed untoward at that point. Ms Douch was also observed by Dr Choi when he looked up towards level 3. He saw Ms Douch standing alone next to the balustrade holding onto it with both hands looking down towards the foyer. Dr Choi did not think anything of it at the time.
Approximately 19.37 hours staff heard a loud thud. Staff immediately attended and saw Ms Douch lying unconscious on the floor between the atrium wall and the foyer office.
A medical emergency call was made known as a code blue. Resuscitation was commenced as staff considered that she may have collapsed.
Unfortunately, it was unsuccessful, and Ms Douch was unable to be revived. The wardsman, who had earlier seen her on level 3, saw the heat pack near her and became suspicious. A review of closed-circuit television showed that the deceased fell from Level 3 to level 2. It is unknown precisely how Ms Douch fell to the foyer, but it was suspected she had jumped given the reasons for admission.
Police were advised of the death and a Forensic Team was called. They examined the area where it was believed that she had jumped from. No fingerprints were found belonging to Ms Douch or anyone else recorded on the NAFIS system. Police also examined Ms Douch’s property and found a suicide note written on a breakfast receipt from The Canberra Hospital.
Police also collected the note which was left at Bombala. Police considered that there was no third-party involvement in the death of Ms Douch.
Ken Alexander Lucas
I made interim findings in respect to the death of Mr Lucas’s death on 4 May 2018 in the following terms; Ken Alexander Lucas (born 19 June 1960) died on 17 November 2016 at 19.30 hours at The Canberra Hospital, Garran, from global cerebral hypoxia caused by Mr Lucas attempting to hang himself from the door of the ensuite in Room G40 of the Adult Mental Health Unit at The Canberra Hospital on 12 November 2016 between 21.00 hours and 22.00 hours History
Mr Lucas was born in Yarram, Victoria. He was the youngest child. His sister died in childhood. Mr Lucas enjoyed sport and motorbike riding and he spent much of his time together with his family on the family farm.
Mr Lucas joined the Victorian railways and served as an apprentice boilermaker/welder.
After completing his apprenticeship, he enjoyed travelling abroad and travelled overseas extensively. Part of his working life contained working offshore as a boilermaker for many years. When he returned home, he lived on the family farm.
In 2012, Mr Lucas attempted suicide whilst working on a large ship off the coast of Western Australia. He attempted this by securing a ratchet strap to an anchor point on the ship and placed the other around his neck and threw himself over the side of the ship.
He was suspended against the ship hull until crewmembers assisted him back on deck and commenced cardiopulmonary resuscitation. He was transported to Perth Hospital where he made a full physical recovery.
Mr Lucas began to struggle after his suicide attempt in 2012. He did not follow up on medical appointments and he did not take his medication. Mr Lucas returned to the company to work on the rigs. At some point the company contacted Brian Lucas, Mr Lucas is brother to tell him that he had left and gone back to Melbourne.
Between 2012 and 2016 Mr Lucas obtain some employment but did not stay in the same job for extended periods.
Mr Lucas formed a friendship with Lily Li. Ms Li had two daughters who Mr Lucas became very fond of and attached to. During this period Mr Lucas’s family was concerned about his mental health and persecutory ideation.
In July 2016, Mr Lucas moved to Canberra to reside with his brother Ian. The family were concerned about Mr Lucas’s mental health and considered he suffered from delusions. Mr Lucas told his brother that he was not taking his medications and it was arranged for Mr Lucas to see a general practitioner for a psychiatric referral.
On 5 November 2016, Mr Lucas contemplated drowning himself at Googong Dam. Mr Lucas decided not to do so and considered that “the world is a beautiful place” therefore he was disinclined to continue with his thoughts of suicide. Ian Lucas contacted the CAT team and made an appointment for Mr Lucas to engage with them.
On 6 November 2016, Mr Lucas was admitted to the Mental Health Short Stay Unit at The Canberra Hospital as a voluntary patient. He was assessed by Dr Modak a psychiatrist who considered him to be ‘At Risk Category 2’. Mr Lucas denied being
depressed or suicidal and was placed on a low dose of medication to treat his anxiety.
Mr Lucas agreed to remain as a voluntary patient.
Between 6 and 10 November 2016, Mr Lucas remained in the Mental Health Short Stay Unit. Staff observed him to have little interaction with either staff or other patients. On 10 November he was transferred to bed 40 of the low dependency unit of the Adult Mental Health Unit.
On 11 November 2016 Mr Lucas was allowed some leave for a short period of time in the company of his brother to purchase a new clothing. Ian Lucas reported that Mr Lucas displayed signs of forward thinking and appeared to care about his appearance.
At 18:59 hours on 11 November 2016, Mr Lucas was reviewed by psychiatrists Dr Ahlin and Dr Modak. At the time of review Mr Lucas’s previous medical notes were not available for review. Dr Ahlin conducted an assessment on Mr Lucas and designated him as an ARC (At Risk Category) score of 2.5. This was a change in his risk score and meant he was to be monitored more frequently and was a substantive increase in the frequency of observations required.
Dr Ahlin advised Dr Modak of his decision and it was relayed to RN Eldridge, who was also in the room, that the ARC score had been changed and increased observations were necessary. RN Eldridge and Dr Modak both signed the Clinical Risk Assessment form (CRA) which updated the ARC score.
The change to the frequency of observations was not followed, and hourly observations were continued rather than every 30 minutes. During that time Mr Lucas was observed by several nursing staff who engaged with him and made observations that he was resting.
At approximately 22:05 hours on 12 November 2018, nursing staff were conducting their regular checks and noted that Mr Lucas was not in his bed. They entered his room where they noted, as they approached the ensuite, a bedsheet appeared to come from over the top of the door of the ensuite door from within. It was noted that the bedsheet was secured to the handle on the outside of the ensuite.
Staff attempted to open the door but were hampered by a chair that had been placed on the inside of the ensuite blocking their entry. They activated their duress alarms and forced their way into the ensuite. As this happened, Mr Lucas fell to the floor. It was observed that he was ashen, and he felt cold. Cardiopulmonary Resuscitation was commenced, and the Medical Emergency Team was called.
Cardiopulmonary Resuscitation was continued, and Mr Lucas was transferred to the Intensive Care Unit by ambulance. Scans were later conducted which indicated that Mr Lucas had suffered irreparable brain damage, his prognosis was terminal and death inevitable.
On 13 November 2016, Police were notified of the incident and attended at The Canberra Hospital Intensive Care Unit. Police observed marks consistent with a ligature on his neck. Forensic officers conducted an examination of room 40 at the LDU where Mr Lucas had been situated.
On 17 November at approximately 7:30 pm, all mechanical devices of life-support were withdrawn. Mr Lucas died a short time later. Mr Lucas donated several of his organs for transplant.
Police conducted enquiries and found no evidence of any third-party involvement or suspicious circumstances in Mr Lucas’s death.
Evidence in Relation to Anthony Leigh Bearham Sue Ellen Tate – Prepared statement read onto the court record “Anthony's life was always full on. He was always smiling, energetic and had a caring nature about himself. He was born in Melbourne and he moved to Port Lincoln in South Australia when he turned one. At the time it was just me and Anthony and we moved to South Australia so he could get to know his father. In 1994 Anthony's little sister, Angela, arrived and we moved to Adelaide with Angela's father, Brian.
Anthony started attending school at Salisbury North where he used to get into a lot of mischief both at school and at home. He liked to wag school and spend time hiding up trees.
He also liked lighting fires. Anthony's behaviour was challenging from a young age and he was removed from my care at the age of seven. He was made a ward of the state and moved through many foster placements. Anthony said that he went through over 50 foster families.
While he was a ward of the state Anthony was diagnosed with ADHD, ADD, OCD and schizophrenia in around 1998.
Although he wasn’t living with us, we saw Anthony three or four times a week and he stayed with us on weekends. He continued with school until year 9 or 10, and after that he started getting into trouble with other kids around Whyalla. Due to his challenging behaviours he moved out of foster care and into his own place at age 15.
The next year I moved with his sister and two younger brothers, Nathan and Jordan, to New South Wales to escape family violence. As a kid, Anthony's passions included motorbikes, cars, but mostly scooters. He wanted to go professional and had pictures taken while performing at Parramatta Skate Park after he moved up to New South Wales to live with us in around 2008.
After moving to New South Wales Anthony met his girlfriend, Cara Mason. Anthony adored Cara and was very happy at the start. Overall, their relationship wasn’t an easy one and I expect it was fuelled by mutual drug abuse. In March 2011 Anthony and Cara had a baby girl called Jasmine. Anthony's greatest love was Jasmine. When she was removed from Anthony and Cara's care only a few days after she was born, Anthony began slipping further and further into depression. He stopped wanting to go out, he just wanted to get high.
Cara and Anthony would often get into heated arguments about trying to get Jasmine home.
This is when he really started to lose control. He was cutting himself quite deep in places and regularly. Anthony was hospitalised in Cumberland for one or two days at a time, only to be sent home where he would do more drugs. The cuts were often to the top of his arms and I saw it as attention seeking rather than serious attempts to take his life.
When Anthony and Cara broke up in 2011, I said he could come home but no drugs were to be brought into the family home. He agreed and things ran smoothly for almost a year, but Anthony was changing. He became reclusive, withdrawn and would go days unshowered and paranoid. If friends called around, he wouldn't talk. His hoodie would go on and he would often sit in his room until they left. Anthony started becoming increasingly paranoid and had apps on his phone so he could listen to conversations. He would argue with me and his siblings, thinking we were conspiring against him. At times he even accused us of poisoning his food.
On the last weekend he lived with me all my family were at home. Anthony had his bag sitting in the lounge room, pockets were unzipped. I walked out from the hallway to see him putting something in his crutch area. When I questioned him as to what he was hiding, he first said, "Nothing, mum." I knew he had something bad, so I questioned it again. He told me it was ice. I was angry and told him he put my grandchild at risk and had to leave.
In retaliation he reached into the bag and took out razor blades and went out front and started self-harming. Police and ambulance were called, and I believe Anthony was placed in Katoomba Mental Health. From there, Anthony was in contact with his brother, said he was going to Victoria to meet a girl from the internet, Facebook.
The next time we heard from Anthony, he said he was in a nice apartment in Canberra, this was his birthday on 30 December 2014. He didn't mention he was in the mental health - just that he was living the high life. The next call I received about Anthony was from the nurses at ICU at The Canberra Hospital at 5.30 am on 5 January 2015, stating that I had to get to Canberra ASAP because Anthony wasn't going to survive. I rushed to Canberra with Angela and her boyfriend, Jake, and I was with Anthony for much of the following day and a half where he remained on life support.
On 6 January 2015, he was pronounced brain dead and I sat with him when they turned off his life support. Anthony was a troubled person, but he was a good person. I miss having him in our lives. His death has turned our lives upside down. I still have nightmares about him, and his brothers and sister are still coming to terms with his death three years later. His death has changed the way I think about suicide because of the impact it had on the people who were part of his life. I hope that Anthony's death and the inquest into it can have a positive impact on the way mental health services provide care for their patients so that it doesn't happen ever again.”
Evidence Constable Samuel Norman
Constable Norman investigated this matter on behalf of the Coroner. He prepared a statement in that regard. Constable Norman indicated that Mr Bearham was found hanging in a bathroom off the Social Spine of the Adult Mental Health Unit (AMHU) on 4 January 2015. He was resuscitated and taken to the Intensive Care Unit (ICU) and remained on life support until his life support was ceased and he was pronounced dead on Tuesday, 6 January 2015 at 3:41 pm. A statement of life extinct was signed by Dr Kumar dated 6 January 2015.
Constable Norman interviewed Dr Kumar who indicated that he had treated Mr Bearham in the ICU after receiving him from the AHMU where he was found attempting to hang himself with a blanket. Mr Bearham suffered a cardiac arrest and a significant period of Cardiopulmonary Resuscitation was administered prior to his transfer to the
Dr Kumar advised that Mr Bearham had multiple scars, some recently inflicted with what appeared to be a sharp object.
At approximately 7:49 pm, Senior Constable Best, Constable Norman and First Constable Moore attended at the AMHU. There they spoke to team leader Andrea Teunissen in the front foyer of the Unit. Ms Teunissen advised that the treating Consultant Dr Gray was not available, and he would be the only person who could provide information to the Police. Miss Teunissen advised that the acting team leader Mr Acks, would be available at 8 am the following morning. It was obvious to Police that they were not to be admitted that evening to the AMHU, as Ms Teunissen told him that Police would not have access to the unit and that they would need to speak to Mr Acks the next day.
Constable Norman asked whether the crime scene had been preserved. This included the ligature used by Mr Bearham, pending a forensic examination to be conducted the following morning. RN Teunissen stated that the door had been locked and the locks had been changed. Constable Norman asked whether RN Teunissen could advise the staff to preserve the scene until Police could examine it following morning. RN Teunissen did not give anyone that message and rode away from the hospital on her motorbike.
Constable Norman then spoke to the shift supervisor Cheryl Andrew who did not give him any information and stated he would have to follow-up the following morning in terms of the crime scene preservation. She advised that she could not guarantee crime scene preservation and if that wasn’t good enough that he should speak to the on-call Director. Constable Norman asked Ms Andrew to contact the on-call Director. Ms Andrew declined to do so but said she would transfer him to the switchboard. She did not advise who the on-call Director was at the time as it is a rotational position.
The switchboard placed him in contact with the on-call Director Cathy Furner. Miss Furner called Constable Norman back and advise that she had spoken to the staff on the ward and confirmed that Mr Bearham’s property would travel to the Intensive Care Unit. Miss Furner could not confirm whether the scene was secure but stated that the deceased was found hanging on the external surface of the bathroom door which opened in a common area of the ward. Miss Furner assured him that the door had been locked and no one would be using it.
Constable Norman was aware that there was a Memorandum of Understanding between the AFP and the Hospital and provided a copy of that document. That document was exhibited before me as CD 9.
During the morning of 7 January, Detective Sgt David Turner continued, at the request of Constable Norman, to make enquiries from ACT Mental Health. Detective Sgt Turner spoke with Michelle Hemming and arranged for the Police to review the scene that afternoon. Ms Hemming also advised that there had been a sheet and a bucket used by the deceased however this was the first-time Police had been made aware of the bucket. Both the sheet and the bucket were not found.
At 3 pm on 7 January 2015, Constable Norman together with AFP forensics services attended the AMHU. The officers were shown to where Mr Bearham had hanged himself, in the northern end of the Social Spine. It was apparent that the lock had recently been changed as there was a quantity of sawdust around the lock and on the floor. The type of handle was a recessed handle with a keyed deadlock.
At that time both Ms Hemming and Mr Acs provided a summary of what had taken place. They stated that Mr Bearham was last seen on the ward alive at 10:20 pm or 10:40 pm. During the medicine rounds at 11 pm the deceased was found not to be in his room. Staff actively looked for him and at approximately 11:50 pm he was located hanging on the bathroom door in the Social Spine. He was suspended with his feet off the ground by a blue blanket which was passed over the door and tied to the internal door handle. An upturned bucket which the deceased had apparently stepped off was nearby on the floor.
Ms Hemming provided the lock mechanism which had been replaced after Mr Bearham was found hanging. The blue blanket said to have been the ligature was now not available as it had been taken from the scene. That made it difficult because Ms Hemming could not provide information as to whether it was the white blanket with the blue stripe or the blue bedspread.
Ms Hemming also produced property belonging to Mr Bearham and these items were handed to the Police. That was despite Police being advised earlier that Mr Bearham did not have any property on the Ward.
Over objection Constable Norman stated that in his dealings with Ms Hemming in respect to taking statements from witnesses.
“ACT Mental Health and ACT Health currently maintain a policy that all requests for interviews with and/or statements from staff must be facilitated through the applicable medicolegal office. Ms Hemming advised that whilst Mental Health staff are encouraged to cooperate with Police and coronial investigations, she tells staff that any such participation in the form of statement provision or interview participation is their personal choice and it is not a compulsory part of their duties. She advised that most of staff are afraid of Police scrutiny and will generally refused to speak directly to Police if given the choice. Ms Hemming will not disclose direct contact details for staff to assist Police in making a face-to-face approach. Attempts made by me to contact staff directly for other matters have invariably been referred back to Ms Hemming’s office and Ms Hemming has expressed a firm view that Police attempts to contact ACT mental health staff directly were inappropriate in all circumstances.”1 1 Transcript of Constable Norman’s Evidence.
Constable Norman said he then requested Ms Hemming make arrangements with the relevant staff of the purposes of conducting interviews. Ms Hemming requested that the matters to be discussed during those interviews be forwarded to her office. Constable Norman provided the information she requested.
Constable Norman stated that Ms Hemming advised him that all remaining staff had declined to take part in interviews and would instead be providing written statements addressing the topics that Constable Norman had provided.
Constable Norman identified that an issue had arisen in relation to the Medical Emergency Notification. It appears there was a medical emergency or code blue initiated but not either acted on or not properly made and a second MET (Medical Emergency Team) call was therefore necessary causing possibly a delay in the arrival of the emergency medical team. Constable Norman was provided with the protocols in relation to both code blue and code black.
Constable Norman requested statements from persons who were involved in that Met call and ultimately those statements were provided.
Constable Norman advised that from his investigation he could find no evidence of the involvement of a third party in the death of Mr Bearham. There were no suspicious circumstances and all available evidence indicates that Mr Bearham committed suicide by hanging.
Constable Norman opined, a recommendation the Coroner could make would be to clarify the protocols relating to code blue and code black. Constable Norman also suggested that the installation of alarms on the top of doors could be a matter for recommendation by the Coroner. Constable Norman also stated that the Coroner might consider the suitability of the so-called ligature safe door handles that were fitted in many of the doors at the unit.
Constable Norman’s opined that the ligature safe handles can be used by attaching a ligature to the door handle and looping it over the door which defeats the effectiveness of the ligature safe handle. It was his understanding that hangings in custodial environments are not uncommon things to see, which is why he suggested an alarm for the top of the door.
Constable Norman stated that he did not have any evidence as to how Mr Bearham was attached to the ligature. The evidence was unclear although someone recalled that perhaps the sheet was jammed in the door. Constable Norman stated that he does not know who removed the ligature and the bucket from the scene. It was patently clear to him that when they did get access to the scene the door handle had been changed because of the amount of wood shavings on the handle and also the floor.
Constable Norman opined and that “in the response to any alleged suicide or suspected suicide, particularly in a custodial environment, establishing the nature of the ligature, the nature of the attachment point, whether or not it was possible for that to have actually taken place whether some foul play may have been involved other key parts of the investigation at that stage and securing those items for subsequent even measurements by forensics and further forensic examination is a key part of that response.”2 2 Transcript of proceedings dated 10 April 2018 (p 39).
Constable Norman opined that there was a lost opportunity in relation to the ability to forensically examine the evidence. As well as in not being able to question the witnesses or to conduct follow-up questioning after he received the witness statements.
Constable Norman said: “as an investigator who interviews people regularly, one of the beauties of a face to face interview is that inconsistencies in the story can be challenged or clarified at the time or you can revisit them after receiving additional statements from other people. You can go back to witnesses and ask further questions to clarify any inconsistencies between witness statements or anything that is not completely clear. The process of being reliant upon the medicolegal team to prepare the statements with witnesses and provide them to me meant that I was only able to take that evidence as it was on face value. There wasn’t any opportunity for me to then ask additional questions of those staff to clarify any of those issues.
The other issue is I guess the effects of memory fade over time. Certainly, it is ideal, and the reason that we do records of conversation at death scenes is very much because that is when the person’s memory is the most fresh, particularly in an emotionally traumatic time. Waiting even a couple of days to do a written statement might result in significant loss of memory during that period. So, we try to obtain a fresh account in the record of conversation, as we did with Dr Kumar there and then at the time.“3
Constable Norman stated, in an answer to a question from me, that memory fade was the theme throughout the statements. He stated that in a number of statements there was reference to not being able to recall specific matters and it was his view that obtaining the information sooner reduces the risk of memory loss.
Constable Norman stated that he was never taken to Mr Bearham’s room and was not made aware, until some significant time later, that there had been a note left which may have had something to do with his suicide and the notes contained theories about life.
Constable Norman stated that he was not taken to Mr Bearham’s room because another patient had been installed in it.
It was his view that the usual practice is to look for things like suicide notes, mobile phones and the like. It was also his view that to some extent failure to examine the scene complicated his investigation.
Constable Norman opined that his inability to conduct the investigation as he would have like, meant that he was reliant on Ms Hemming and her Office to conduct the investigation for him. Noting that they are not trained investigators. That gave a perception of bias as they were the medico legal team investigating, giving legal advice, and also taking statements.
Matters raised with the team as to areas of investigation were not satisfactorily addressed in his opinion. Constable Norman felt he was collating the material provided by them not truly investigating the matter.
Constable Norman made the comment that this did not happen in any other death scenario. Usually witnesses are cooperative and full access to the scene is granted and full co-operation is given in usually all cases. It is rare to be refused except for those involving matters involving ACT Health.
3 Transcript of proceedings dated 10 April 2018 (p 40).
Constable Norman further commented that he considered there was a perception that the ACT Government Solicitor, who essentially assists witnesses from the health sector to provide the statements in relation to incidents, sanitises their statements.
It was his view that because he was unable to establish face-to-face access with the witnesses involved in this case, he was not able to establish their degree of understanding about what their rights were in providing statements. Constable Norman also was unsure about their understanding of whether it was their choice or whether they were authorised by the organisation not to provide direct statements to the Police.
Constable Norman contrasted this to the Memorandum of Understanding between ACT policing and Corrective Services, where witnesses to an incident provide statements to Police as required despite their private ability to decline. It is a condition of their employment that they do so. That is because of the custodial setting in which they work.
Constable Norman argued that to some extent this should be applicable to the ACT mental health setting as well.
Constable Norman disagreed that Ms Teunissen advised him that she would need to seek directions from the director on-call about access being granted to the Police on 6 January. Constable Norman advised that she was quite flippant and made no effort to assist him. Constable Norman disagreed that she had said words to that effect and in fact stated that had she done so, he would have asked her to contact the director on call.
In respect to Ms Andrew, Constable Norman stated that she did not assist him to contact the director on-call. It was his view that she was quite flippant the whole time and did not assist him in any way. It was suggested that she put him through to the switchboard so that he could contact the on-call director. However, he stated that was not the case and he had to explain who he was and what he wanted. It was at that point that the switchboard operator gave him the number for the director on-call Ms Furner. Constable Norman noted that he has never received a statement from Ms Teunissen or Ms Andrew.
Constable Norman agreed that when he spoke to Ms Furner, she told him that all items of property would be transferred with the patient.
Constable Norman agreed that he had been shown two different types of bedspreads assumed to have been used as a ligature. In relation to his enquiry about the lock mechanism for the door, he did discuss it with both Ms Hemming and Mr Acs and they were unable to advise him as to why the lock was changed. However, Ms Hemming stated she would make enquiries. Constable Norman was never given any information about why it was changed. However, in his view it was obvious. In respect to Mr Bearham’s property, it was Constable Norman’s impression that Mental Health had misplaced his belongings because he’d been transferred to the ICU and no one had seen any property there belonging to Mr Bearham. Constable Norman opined that it was most likely that his property was never taken away from the AMHU because it was found there later.
It was suggested to Constable Norman that Ms Hemming’s practice is to encourage people to participate and cooperate with Police and advise them that there is a power to summons a witness if they fail to cooperate. Constable Norman said he does not know either way what her practice is.
It was suggested to Constable Norman that Ms Hemming has never expressed a view that she will not give Police direct contact details for staff for the process of assisting them in their investigation. Constable Norman disagreed and said that he had spoken to her and she had told him that.
Constable Norman gave an example of that very issue having arisen in another matter.
Constable Norman also said that he has contacted Ms Hemming regularly in most investigations and had the same issue. It was suggested that he may have been confused as to her intention. He made it quite clear that he was not confused and that she has refused to make available contact details for him to contact potential witnesses directly.
Constable Norman also complained in relation to the lack of clarity about the manner of the ligature and where it was placed. It was suggested to him by Counsel that he did not follow up with Ms Hemming in respect of that and he said that was true. He said that was because he was resigned to the fact, he was unlikely to receive anything more than what had already been received.
Constable Norman stated that he was asked to provide specific matters to Ms Hemming to be dealt with in the statements of the witnesses. It was Constable Norman’s view that these matters were not dealt with as he would have liked, and he was also clear that that was all he was going to get. The brief preparation ran late because it had taken a significant period of time to get the statements together and he submitted the brief as soon as he received those statements.
Constable Norman accepted that he could have contacted Ms Hemming after the brief was submitted however, he did not do so. Constable Norman accepted that a number of statements had been given to him some 10 weeks prior to him signing his statement and that he could have asked follow-up questions.
Constable Norman agreed that by the afternoon of 7 January he had been given Mr Bearham’s belongings and had been shown the area where the suicide took place.
Constable Norman agreed that he had been given a lock mechanism however he pointed out that he did not know whether it was the one in question. He also observed that the lock mechanism had been changed between when the incident took place and when he attended the next day.
In terms of the Memorandum of Understanding between ACT Mental Health and the Police, Constable Norman opined that it was not fit for purpose because it mainly dealt with consumers in the community rather than in a supervised unit. It did not address issues such as those that arose in this circumstance where Police should have access to a scene whether it’s non-fatal or not.
Constable Norman was asked about his concern about staff not feeling free to talk to Police, and he said that he was concerned about that fact. Constable Norman agreed that Ms Hemming does give staff options and recommends that they participate in at least one of them.
Constable Norman stated that he was concerned because staff who may wish to make a comment which is detrimental to the interests of their employer cannot do so if their statements are submitted by and through that employer.
“in any investigation, the best practice, where possible, would be to take statements as soon as possible from as many people, as quickly as possible”.4 Richard Gray
Dr Gray is a psychiatrist who first encountered Mr Bearham on 27 December 2014 in his role as psychiatrist on call. His role was to assess Mr Bearham in relation to an Emergency Detention Order.
Dr Gray examined Mr Bearham and concluded that he was suffering from a methamphetamine induced psychosis and that it had largely resolved, and he was returning to his baseline mental state. It was his view that he probably presented as mentally dysfunctional rather than mentally ill as it was short lived, and he was responsive to treatment.
Further criterion that Dr Gray considered was that Mr Bearham was accepting of mental health treatment and care. Therefore, he did not meet the criteria for a further extension of his Emergency Detention Order. Dr Gray stated that Mr Bearham was in the High Dependency Unit when he was first assessed. His risk assessment was reassessed, and he was marked from an ARC 3 down to a 2, when he was in the low dependency unit. The difference being ARC 3 is a 15-minute observations and ARC 2 is hourly observations. Mr Bearham had denied any thoughts of self-harm at that review.
27 December was Mr Bearham’s birthday, and he had advised that he planned to have a barbecue with some friends and that he could stay with them.
Dr Gray opined that Mr Bearham had continuing improved insight on 30 December from that he displayed on 27 December. In his view, that was consistent with the drug induced psychosis continuing to resolve. Dr Gray, after considering all the criteria required, allowed two hours of leave to Mr Bearham on the proviso that he did not consume any illicit substances or alcohol. Dr Gray noted that he was given leave of two hours on three occasions and he had returned within the time allocated and had not displayed any signs of intoxication or behavioural disturbance.
Dr Gray reviewed Mr Bearham again on Friday, 2 January and from his clinical observations and the notes of Dr Soh it appeared that Mr Bearham had consumed methamphetamine which left him with a returning psychosis. Although he wasn’t agitated and aroused, and it was clear in Dr Gray’s opinion that he did not want Mr Bearham to become stuck in the hospital system or his condition to regress and deteriorate. The issue of calls to find accommodation was significant in relation to when he would be discharged, and it was Dr Gray’s view that perhaps Mr Bearham was trying to defer his discharge because of his homelessness.
Dr Gray stated that it was his view that he could be discharged once his accommodation was settled but that did not appear to be in the foreseeable future.
Dr Gray was made aware that on the day he was given leave, he did not return at the specified time. That was the last time he had clinically treated or reviewed Mr Bearham.
In hindsight, the only instruction he would have made more explicit was for a Clinical Mental State Examination to be conducted when he returned late from leave.
4 Transcript of proceedings dated 10 April 2018 (p 60.33).
It was suggested to Dr Gray that Mr Bearham was late back from his leave, he apologised for coming back late and described his experience as having a psychotic episode. At about 18:30 hours, Mr Bearham was observed to have a soft drink can which had been cut in half and threatening to slash his arms. Staff intervened and he handed them the can. At approximately 19:00 hours, he was observed to have several superficial cuts to his face and his left arm. Dr Gray agreed that in that situation that would have been a concern and a further mental state examination should have been conducted. Dr Gray also agreed that this behaviour was consistent with being under the influence of methamphetamines. Dr Gray opined that it was a little surprising that the ward Registrar was not notified of this situation.
It was clear from answers to questions I raised that Mr Bearham was deteriorating after he returned from leave. Clearly, he was coming down from drugs, which we now know he took, yet he was not seen by the Registrar. Dr Gray opined that given the Registrar is in the Emergency Department Psychiatric Unit and would have been very busy he speculated that the RNs may have been reluctant to call them.
Dr Gray was asked whether he could make any recommendations for the coroner to consider, and he said chronic bed shortage and understaffing was always a problem.
That made decisions in relation to discharging patients critical particularly so on weekends and holidays. Had there been greater flexibility with medical staff, the reluctance by the RNs to contact medical staff would be lessened.
Bernadette Duffy
Bernadette Duffy was a registered RN at the time of Mr Bearham’s death. Ms Duffy trained in France and had 16 years of experience working in intensive care, oncology and some work for alcohol and drug addicted persons.
RN Duffy commence working for The Canberra Hospital in January 2007, at that point she had no mental health RN training.
RN Duffy was at work on 4 January and recalled seeing Mr Bearham but had no direct dealings with him. RN Duffy was rostered on the night shift. She was a semiregular on that shift. RN Duffy was familiar with the practices of the ward.
RN Duffy said that she would receive hand over between 21:00 hours and 21:30 and would then commence observations from approximately 22:00 hours. Generally speaking, the observations would require 2 RNs to conduct it.
RN Duffy observed Mr Bearham sitting in the dark at approximately 22:00 hours in the games room he had his phone with him. Mr Bearham was asked to leave the room as they had to lock it. Mr Bearham moved to the Social Spine and was listening to his phone. RN Duffy asked Mr Bearham what he was doing, and he told her he was speaking to a friend from America on a free channel on his phone. She said he had a radio playing on his phone which had voices talking.
Ms Duffy was asked who was on observation rounds with her, but she could not recall the name of the RN. RN Duffy advised that after the events of 4 January, she was not asked to write a note or recall the events. However, she said that she generally would give a hand over. At the time she did not have access to the MHAGIC notes. RN Duffy
wrote a note which was recorded in the brief. That note was written at 02:15 hours. RN Duffy noted that Mr Bearham had asked for Valium and was given that at 22:45 hours but not by her. RN Duffy also noted that her observation of Mr Bearham was that he indicated a lack of awareness of reality. However, he did not appear harmful, aggressive or threatening to himself or others.
RN Duffy recorded that they commenced the second round at 23.35 hours which was a bit late. RN Duffy could not identify why she had filled in 22:00 and 23:00 hours but may have filled them in earlier in the night. There was no signature in the signature column on the observation sheet. RN Duffy said at the time they would put the times in the column which were approximate times for the observations. However, after Mr Bearham’s death people were told to be more precise and a review had been conducted in relation to that.
Ms Duffy recorded that Mr Bearham was found hanging, CPR was commenced a MET was called he was transferred to ICU.
In relation to conducting the observation rounds, she said they commenced at 23:25 hours. RN Duffy said it took between 10 – 20 minutes to complete the round. RN Duffy marked on the plan where Mr Bearham’s room was, which was in fact G 40 at the end of the green corridor. RN Duffy stated that when she attended his room, he was not in it. Although she did say she found a piece of paper lying on the bed. She identified it as a document in the brief. Ms Duffy said she did not touch the document but recalls it had some words on it, ‘some days are blue some days are diamonds’ and considered it to be positive message. RN Duffy said that she had not seen that document since the time she was preparing her statement and was quite shocked when she did see it. RN Duffy did not recall seeing any of the other notes.
In her statement, she stated that she had then continued her round and checked the rest of the Orange Wing however when shown the diagram, in evidence she indicated that she continue down the corridor from Mr Bearham room to the Social Spine, which took approximately 5 to 7 minutes.
RN Duffy stated that when she arrived at the Social Spine, she looked toward the therapy wing and saw Mr Bearham in the doorway of the toilet. RN Duffy went straight to that area and then discovered that he was hanging from the toilet door. RN Duffy put her arms around his legs to take the weight from his neck. RN Duffy said the ligature was made from the blue cover used on bedding generally in the hospital.
RN Duffy stated that she pressed her duress alarm several times and waited for assistance. Pressing the device twice means a code black, it indicates urgency and extra help is needed. RN Duffy indicated that help should arrive within 90 seconds of the call. When the wardsman arrived, he took over holding Mr Bearham and she released the knotted bedspread from over the door.
RN Duffy said she was not sure how the bedspread was affixed to the door, but she said she thought it was just a big knot which was blocking it from going down when over the door. She had no recollection of having to untie the cover from the door handle. She recalls having to jump on the bin to untie the knot or slip it from the door, but she has no clear recollection. However, she does recall that the bin was to the side of him.
Unfortunately, she was unable to be precise as to the mechanism of how he was suspended.
RN Duffy then, with the help of the wardsman, commenced CPR and another RN ran to the RNs station to call a code blue. RN Duffy stated that within a few minutes a wardsman from the hospital arrived and told her that the code blue had not been activated. RN Duffy had no clear recollection of when that occurred. RN Duffy indicated that when the RNs had been speaking to her after the event that evening, they said that the code blue mechanism hadn’t been working and they had to call on the telephone.
Eventually the medical emergency team arrived and took over the CPR and ultimately Mr Bearham was transferred to the ICU.
RN Duffy wrote a note indicating that the patient was unconscious, grey in colour, pupils not reactive, CPR started and transferred to ICU. RN Duffy said that once the emergency team had arrived, she withdrew from the area and allowed them to do their job.
RN Duffy stated that she had asked what happened to the ligature (bed cover) because she considered it was important. However, she was told that had been taken into the linen bin with other linen and then emptied.
RN Duffy said she did go to Mr Bearham’s room because she was worried, she had missed something, but the items were not there when she went into his room. RN Duffy was unaware of what happened to Mr Bearham’s belongings that night.
RN Duffy stated that the only training she had prior to commencing on the AMHU was the compulsory program ‘how to manage a difficult patient’ training which she has been ‘vetted on’. It comprises three and half days of training.
RN Duffy recalls that prior to 4 January, she was advised that Mr Bearham had scratched his face and it was associated with some leave he had taken. RN Duffy said that she was aware that people who are at risk of self-harm are generally not on an ARC 2 and that they are usually on one-to-one observations and kept an eye on much more often. RN Duffy stated that she did not have any training in relation to identifying signs which would give her concern in relation to risk of suicidality.
RN Duffy stated that the ligature around Mr Bearham’s neck was the bed sheet which was large. RN Duffy recalled that it took a long time to get him free from the door so that they could place him on the floor. RN Duffy stated that the door was not completely closed and had a little space open.
RN Duffy stated that she had to go inside the door, but she was not completely sure how she did so.
RN Duffy agreed that it was a long time ago and she was having difficulty recalling events. It was suggested that, had she been asked questions about this on the night, it would have been easier for her to recollect. RN Duffy agreed and stated that nobody asked her to write any observations down, but she did so because it was an incident and they always must report them.
It is clear that RN Duffy did not write in the MHAGIC notes but was beside the person who did so. In that note, it is written that Mr Bearham was preoccupied, paranoid and fearful. However, RN Duffy stated she did not write those words. In her view she would have commented that him saying he was talking to someone whilst listening to the radio was a distortion of reality.
RN Duffy indicated that she had no specific training in relation to preserving a scene of an incident, but it was her own belief that writing a note was important to provide detail.
Euphrasia Marafu
RN Marafu was a registered RN with a postgraduate qualification in midwifery, nursing administration, and a master’s degree in nursing science. RN Marafu also had mental health training in her general training program. RN Marafu has worked at The Canberra Hospital since 2008. Since that time, she had worked at the AMHU at The Canberra Hospital.
RN Marafu made statements in relation to this matter in March 2015 and April 2018.
The earlier statement sets out the things that were personally known to her or were discussed with her.
RN Marafu was the team leader on 4 January 2015 on the overnight shift. The shift commenced at 21:00 hours and concluded at 07:30 hours.
RN Marafu identified the note that she had written on 3 January 2015 at 05:38 hours.
In it she identified Mr Bearham as still psychotic, distressed with nightmares and was given diazepam. He was sitting in TV room throughout the night. RN Marafu could not recall the notes of that night nor anything in relation to Mr Bearham.
RN Marafu indicated that information was taken from the previous shift RNs.
RN Marafu recalls that on 4 January she observed Mr Bearham taking his medication at the RNs station. RN Marafu recalls that the ward was full on that night, and there were two patients being specialled. It was her duty to allocate the nursing staff.
RN Marafu recalls that the ward was extremely busy and there was an aggressive patient in the HDU and she was involved in dealing with that patient. RN Marafu recalled that she allocated RN Duffy and RN Preston to complete the observation rounds.
RN Marafu wrote in a statement in 2018 that she had become aware of the duress call being activated on 4 January. RN Marafu described how the device works and said that if you press it once it’s a code black you press it twice a wardsman comes from the hospital. The device indicates exactly where the incident is or where the button has been pressed.
RN Marafu said that when the device had been activated, she ran out immediately from the RNs station and saw RN Duffy trying to lift Mr Bearham by the top of his legs. RN Marafu stated that she asked another RN to call the code blue. She could not remember which RN it was but suggested it was the RN who collected the trolley.
RN Marafu stated that it was her memory that it was the blue bedspread that had been used as a ligature. RN Marafu also remembered a turned over bucket.
RN Marafu said that she recalled that a wardsman from the hospital told her that the code blue had not been called. It was at that time she called the main switch board to confirm that the code blue had been called.
RN Marafu stated that she went to Mr Bearham’s room after he had been transferred to the Intensive Care Unit and was given drawings which had been found there and
collected by other RNs. RN Marafu has a recollection of the first document, which was the drawing. She does not however remember the others.
RN Marafu also saw some sharpened paddle pop sticks which had been found in Mr Bearham’s room. They had been located in the pockets of his clothing. All of those items including the drawings were placed in his file.
RN Marafu was of the view that she had instructed staff to keep the sheet and anything else related to the incident because she thought it would be required in evidence.
RN Marafu stated that she instructed another RN to collect the belongings of Mr Bearham, including the paddle pop sticks in his clothing and the drawings, and place them on his physical file and it was to go to the ICU. RN Marafu does not now know who that RN was.
RN Marafu said that she locked or attempted to lock, the toilet area where the incident took place. However, the locking system was not good, and a direction was given to change the locks on all of the toilets. This was recommended by the manager Helen Braun.
RN Marafu was not given any information as to where the bed cover or the bucket had been taken. In answer to a question about training in scene retention, RN Marafu said that training would be beneficial in relation to preserving a scene. RN Marafu indicated that they now have training in relation to that issue. It is in-house training, face-to-face involving Police meetings and the like.
RN Marafu was aware of other suicides in the hospital since Mr Bearham’s death.
Training has been provided in response to attempted suicides. That training is ongoing, with a RN educator or manager organising for people to come and give training on it.
RN Marafu indicated that RNs did pre-fill the ARC observation scores. However, that is now not the practice.
RN Marafu indicated that she was not told that she could speak to the investigating officer who was acting on behalf of a Coroner to investigate the matter. RN Marafu indicated she was not sure that she would speak to that officer however, she was advised that she may be called as a witness by Ms Hemming. RN Marafu said she used her notes that she’d written on the morning of the incident to assist her in that regard.
RN Marafu identified that she had been given options as to how she would prepare her statement and she chose the first option.
Taylor Schmidt
Mr Schmidt is a wardsman at The Canberra Hospital and has been there approximately eight years. On the night of the incident he was performing services in the Adult Mental Health Unit and had been there full-time in 2015 and currently holds that same position.
Mr Schmidt’s tasks are to assist the RNs with daily patient care and staff safety. Mr Schmidt usually works in the high dependency unit.
Mr Schmidt provided a statement but at the time of giving evidence was a little fuzzy as to its content. In his statement he recalls on 2 January observing some behaviours but indicated that they did not warrant a report. Behaviours which would require reporting would be things such as feeling very down or any expressions of self-harm.
On 4 January 2015, Mr Schmidt responded to a duress call. This call came through the computer system and he was able to precisely tell where the incident had occurred which was near the public toilet in the Social Spine. Mr Schmidt identified a code black as meaning staffing danger or personal threat.
Mr Schmidt attended the toilet area and saw that RN Duffy was holding Mr Bearham’s legs. Mr Schmidt grabbed him around his chest and lifted him up. He observed Mr Bearham to be blue. He also observed a bin near him, and the contents of the bin were on the floor.
Mr Schmidt released the knot from around Mr Bearham’s neck laid him on the ground.
Mr Schmidt then advised the head wardsman of a code blue situation and commenced CPR. When other wardsman arrived, they took turns to continue the CPR.
Mr Schmidt opined that the ligature was fixed over the top of the door and tied to the door handle on the other side. Mr Schmidt said it was RN Duffy who released the sheet from the top of the door, and he assumed that the ligature had been fixed to the door handle.
Mr Schmidt indicated that he did see the bed spread which had been used as a ligature near the low dependency unit RNs office that evening. It was lying on the floor; he does not recall what happened to the bed sheet.
Lee Wuan Tong
Ms Tong was an assistant in nursing who qualified in 2010. She began work at The Canberra Hospital in 2011.
Ms Tong’s only interaction with Mr Bearham was when Mr Bearham defended an RN against a verbally aggressive patient on 3 January.
Ms Tong also observed Mr Bearham on 4 January and noted that he was muttering angrily to himself, which she considered to be similar to the behaviour she observed the night before. At no time was he angry to the RNs and was in her words ‘unfailingly polite’.
Ms Tong said that she was on shift to special a client but was not required. Ms Tong heard an RN shout that someone had hanged themselves and she asked whether they required help. Ms Tong also saw RN Diaz get the crash cart or the MET trolley.
Ms Tong was in the middle of the Social Spine and was heading toward the shouting when she was asked to call a code blue. The code blue activated. However, she did not call anyone after it had activated because she had assumed that the RN would have done so.
Ms Tong then went outside to wait for the team to arrive. Two wardsman in a red car arrived and she directed them to the area where Mr Bearham was. Following that five wardsman arrived and advised her that a code black had been called but not a code blue. She was advised that the first wardsman to arrive had called in the code blue confirming that it was not a code black.
The medical emergency team arrived with the shift manager approximately 15 minutes after she had called the code blue on the buzzer. Ms Tong showed them to where Mr Bearham was situated.
RN Marafu asked Ms Tong to do a round of the facility with RN Mervic. Ms Tong attended Mr Bearham’s room and observed a few drawings as well as his clothing. The drawings were found on the table near the windowsill piled together. Ms Tong stated that there was no suicide note found.
Ms Tong said that she did not remove those documents and did not see Ms Mervic take them either. Ms Tong did not take any of Mr Bearham’s clothing or belongings.
Ms Tong stated that during the course of that shift, a further code black was called after a patient had become aggressive. That happened around 4:00 or 5:00 am.
Ms Tong stated that she received an email from Ms Hemming in respect to how she wished to provide information in relation to this matter and she decided to give a written statement. She did so under the guidance of a solicitor retained by the RNs union.
Ms Tong stated that when she pressed the code blue button she observed the LED panel light up to say that the code had been activated. Ms Tong was unsure as to the sound however, it must have been sounding because she had to take some clients back to their rooms after they had come out of their rooms.
Ms Tong stated that she was not aware of the usual policy that the person who pressed the buzzer also made a phone call. Ms Tong stated that she was reliant on the registered RN who directed her because she was an assistant in nursing. It was also because someone else possibly had already made the call. It’s her position that if she was asked to hit the code blue button everything else will just follow, phone calls will be made, the crash cart would be collected and it was her job to make sure the rooms are clear. Her training was fairly limited.
Cheryl Andrew
RN Andrew work at the hospital consisted entirely of working in the mental health wards.
In January 2015, RN Andrew was the team leader of the shift. In her time as a RN she has not had any experience in relation to the investigation of the suicide death of a patient, or attempted suicide of a patient.
In January 2015, she had an understanding as to her authority in respect to access by investigators including members of the Australian Federal Police. It was her view that, in her dealings with Police, she could only give information that was relevant to what she had witnessed. Anything else had to go to the senior management. In January 2015, that person was the director on call who was usually a doctor or a person in senior management.
RN Andrew recalls that she received a phone call from a male policeman late at night in January 2015. At that point she was the team shift leader. RN Andrew stated that the officer asked for permission to come onto the Ward to set up a crime scene. She advised that patients were asleep, and the area was in the main social area with
patients having free access. Therefore, she was unable to give her permission without talking to the director on call.
RN Andrew recalls that she did call the director on call, who was a female. It was a pleasant conversation and the director on call told her that the Police would not be coming onto the ward. RN Andrew was also told that she had done the right thing by referring the matter to the director on call because she did not have the authority to provide access.
RN Andrew clarified and said that the director on call did not direct her to not let them in but said that Police would not be attending that night and would not be coming onto the ward. RN Andrew did not recall the policeman asking her to call him back, although it is possible, he did request that she do so. RN Andrew said that had he done so she would not have refused a request to call back.
RN Andrew stated that at no time during the shift handover was she told that there were Police officers waiting on the Ward to speak to the shift manager. RN Andrew said that if that had occurred, she would have gone out and spoken to the Police.
RN Andrew confirmed that she told Constable Norman that it was not possible to preserve the crime scene because it was in the middle of the ward, and that she could not give any guarantee that the crime scene and any property items could be preserved.5 RN Andrew was of the view that the door lock had been changed as it was done before she went on duty.
RN Andrew did not remember declining to contact the on-call director for Constable Norman but confirmed that she did not believe she did do so. RN Andrew stated that she did not take any notes given the patient had already been discharged from AMHU.
However, it was her usual practice to keep notes of interactions with Police in these matters. The reasoning being that the file had been transferred with the patient and she didn’t have any access to the file, so she made no note. Once the patient had been discharged, she was unable to access the MHAGIC system either.
RN Andrew said that she has had training in preserving a critical incident or crime scene insofar as she was aware that if an incident occurred, they would remove the patients from that area and keep it as free from interference as possible. In terms of collecting items of relevance she said that she would bag them and keep them aside.
RN Andrew stated that she was not contacted by anyone, Police or otherwise, to make a statement and has not, at the time of the inquest, made a statement. RN Andrew stated that had she been asked she would have provided a statement to Police in relation to this matter.
RN Andrew, in relation to recommendations, stated that work should be done in respect to Police seeking access for information at night. RN Andrew opined that education in the form of information sessions involving Police and senior staff would be important in that regard.
RN Andrew also confirmed that it takes seven minutes for people to come from the main hospital when a code blue or a code black is called.
5 Transcript of proceedings dated 12 April 2018 (p 218.21)
Andrea Teunissen
Ms Teunissen is a registered mental health RN employed by ACT Health. In 2015 she worked in the AMHU and had done so since 2000.
RN Teunissen indicated that she has had experience in dealing with Police who are investigating significant incidents such as a death of a patient or an attempted self-harm or assault.
RN Teunissen did not recall any dealings with Mr Bearham prior to his suicide attempt.
RN Teunissen worked on 6 January 2015 in the afternoon shift for 1 pm to 9 pm. RN Teunissen acted in the role of team leader for the shift.
RN Teunissen indicated that had Police contacted her in respect to an incident, she would have deferred to the on-call director to get guidance and direction. RN Teunissen indicated that it would be highly unusual for Police to turn up after business hours at the unit.
RN Teunissen did not recall any discussion with Police on the evening of 7 January.
However, after considering Constable Norman’s statement, she had a vague recollection that Police did come. RN Teunissen said it was highly likely that she did tell the Police that Dr Gray was the consultant, who was not working at the present time, but who would the person to provide information.
It was also likely that she told Police that the acting team leader John Acs would be on duty at 8am and he could provide the information. RN Teunissen indicated that she would normally leave the ward on an afternoon shift at approximately 9:30 pm.
RN Teunissen indicated that she had no recollection of whether she knew where Mr Bearham’s personal belongings were. Nor could she recall whether she was aware locks had been changed or whether the scene had been secured.
RN Teunissen had no recollection of the suggestion in Constable Norman’s statement that she was asked to pass a message to the shift supervisor but did not do so and then rode out of the car park without passing the message on. However, she said it was highly likely that she would not have done so. RN Teunissen indicated that there is a telephone which could be picked up to call nursing staff directly and she would have called them if asked.
RN Teunissen indicated that the only explanation for what occurred according to Constable Norman, is that she was of the view that someone else had been looking after them. RN Teunissen was of that view because she would not have been obstructive of Police.
I note that she had very little recollection of the matters she was questioned about whilst giving evidence, most likely because she had not provided a statement earlier.
RN Teunissen confirmed that where such a critical incident had occurred, they would rely on their practices and procedures. It would be expected that the direction would come from management generally during the day, such as, unit manager or director of nursing, director of medicine, or director of psychiatry.
RN Teunissen confirmed that she has no recollection of being directed to retain any item said to have been part of the attempted suicide. Nor does she recall being asked to provide any information to either Police or anyone else in respect to the death of Mr
Bearham. It was her view that she wasn’t a relevant witness, given that she was not there at the time of the attempted suicide.
John Acs
Mr Acs is a RN and was working at the AMHU the time of Mr Bearham’s death. At that time he was the assistant director of nursing, having commenced in that position on 5 January 2015.
Part of his duties as administrative head for the unit were liaising with the clinical consultants about clinical matters, liaising with senior management in relation to reportable incidents, and reviewing risk man reports.
RN Acs did not have any direct contact with Mr Bearham. RN Acs stated that the first time he was asked to find the whereabouts of Mr Bearham’s belongings was the email sent him from Ms Hemming’s on 7 January 2015. It was his view that the usual practice would be for all belongings to be transferred to the ICU.
RN Acs agreed that he sent an email suggesting that the only items of Mr Bearham’s were his clothes and they had been sent to the Intensive Care Unit on 4 January at 23:50 hours
RN Acs stated that he was aware that the bathroom door had been locked because he commissioned a locksmith to lock the bathroom. They were on the direct orders of the Executive Director on 5 January. The purpose of doing so was to close the area and re-evaluate the risk given the incident that had occurred there. RN Acs said the handle that had been on the door where Mr Bearham was found hanging was collected and place in a plastic bag and put in the office. RN Acs advised that a total of five locks were replaced. That was completed on 6 January.
In relation to Mr Bearham’s room, RN Acs said that the room had been cleaned and was in use when he commenced work. In relation to the missing bedsheet and bucket, he was aware that they had been missing. RN Acs opined that the bedsheet was thrown into the linen skip. RN Acs conducted inquiries into the missing items but could not find them. However, Mr Bearham’s belongings were delivered to his office in a brown paper bag. RN Acs presumed they been brought back from the ICU by a wardsman.
RN Acs recalls speaking with Police and showing them to the bathroom on the Social Spine, where he unlocked the door of the bathroom used by Mr Bearham. At that time, he recalls telling Police that the locks had been changed. At the time he provided Police with a summary of what he had been told about what happened on the night Mr Bearham attempted suicide. The information came from the ‘riskman’ which had been filled out by the night staff.
RN Acs also recalls taking the Police officers to the linen room, but he could not identify the particular item used in the hanging from those items in the room. However, he was able to show the type of blue bedspread that he thought was used. RN Acs also provided them with the lock to the toilet door which they appear to be interested in. RN Acs suggested that rather than a bucket it was likely he advised it was the plastic bins in the toilets that may have been used, but he was unable to locate the waste bin.
RN Acs had no recollection as to why Police advised that they could not find Mr Bearham’s property. RN Acs stated that he told Police that the belongings had gone to the Intensive Care Unit and had been returned to the Ward that morning.
RN Acs confirmed that the first time he was asked to locate any items believed to relate to Mr Bearham’s attempted suicide was 7 January. Staff had looked in the linen room to see whether they could find anything and were unable to determine the items used by Mr Bearham.
RN Acs also confirmed that the personal belongings that he asked ICU to send back were indeed only those items that he was transferred with not the personal belongings from his bedroom.
RN Acs indicated that he has received training for critical incidents, such as suicide and the like, and advised that the training is to secure all possessions for the Police investigation and seal off the room. If the patient is transferred, it’s a different procedure and is more like the normal transfer to another ward.
Prior to Mr Bearham death, RN Acs was not aware of any other attempted suicides at the AMHU.
RN Acs was not given any opportunity to give a statement to Police. However, he did not believe that he had any information worthy of a statement and he wasn’t approached by anyone to give one.
RN Acs said there had been a risk assessment done in relation to the door handle and they were identified as being a ligature risk and that is why they were changed.
Catherine Furner
Ms Furner was as at 12 April 2018 the Operational Director Child and Adult Mental Health Service. Ms Furner gave evidence that in January 2015 she was the after-hours director on call for the AMHU. She was point of contact between the hours of 5 pm and 8 am.
Her role commenced when she was contacted by staff who required her assistance.
Ms Furner was contacted when Mr Bearham was transferred to the ICU on 4 January.
It was her duty to contact the Executive Director of the Mental Health, Justice Health, Alcohol and Drug Service, Ms Katrina Bracher. Her role was to ensure that notification was done but it did not necessarily need to be done by her.
Ms Furner attended the AHMU at approximately 04:25 hours when she was aware the consultant on call would be going to the Ward. That person was Anna Berger. Ms Furner stayed at the hospital until the operational director Ms Deborah Plant arrived. Ms Plant would have taken over the operational logistics particularly in relation to clinical matters.
Ms Furner said that the incident was treated by staff as a clinical and medical issue given that he had been transferred to the Intensive Care Unit. It was not her duty to concern herself with preserving the scene or anything of that nature because they are clinical issues, and she at that time did not really know what happened. Ms Furner was not consulted in relation to any matter regarding Mr Bearham’s personal belongings, his room or indeed where the incident occurred.
Ms Furner said she did have a conversation with Police who asked her whether she knew anything about Mr Bearham’s personal belongings, and she did make some
enquiries. Those inquiries were made to the RN in charge of the unit and Ms Furner was clear that she would have told the Police officer enquiring that she had made those enquiries. Ms Furner had no clear recollection of doing so.
Ms Furner indicated that she had not had experience of a death in the unit prior to Mr Bearham’s death. Ms Furner indicated that if Mr Bearham had died on the ward that would have been a different scenario. Ms Furner said had this been the case, she would have contacted the Executive Director to receive instructions in relation to the process because she did not know the process if a patient had died on the Ward.
Ms Furner said it would have been a different process to that of a person who had a non-survivable self-inflicted injury because the process has now changed. The process now includes notifying the Police if there is a nonsurvivable injury, after consulting with the Consultant in charge who would liaise with ICU and Police.
Ms Furner said that the attempted suicide by Mr Bearham on the Ward was the first suicide on the Ward that she was aware of.
Ms Furner also indicated that she took no notes at the time and was not consulted about providing a statement to Police. There had been no recommendation that she should take notes of any of her dealings in these sorts of matters either. Ms Furner agreed that a policy could be implemented covering this could be useful. Ms Furner indicated that at the time she did not consider her information relevant, but now sees that it could have been relevant.
Evidence in Relation to Nicola Joy Fisher
Once Mum was in the hospital, all I could think of were the positive things about her and how confident I was that I would be able to list them to her, so she would realise how much I cared. Having those words die on my lips has been one of the hardest parts of this for me. Despite this, the memories that remain with me are those many little moments of connection we had. The wordless ways she found to tell me that she was proud of and cared for me, but she’d also tell me in no uncertain terms, with thousands of little compliments about my clothes, my cooking, my work, my patience, my ability to help the 5 boys with homework without tearing out my hair.
This past week, if feels like I’ve remembered millions of mundane, tiny things we did together over the past few years to repair and strengthen ourselves and our relationship and to try and work out the Best way of supporting my 10 brothers. To them I just want to say that, although I know it would be an understatement, that there were difficult times in your stories with Mum as well, there were so many times I felt so strongly, her love and concern for you both”. (Indistinct) now also provided some reflections from now. “My Mum had a troubled, turbulent life full of disrupted relationships and conflict, but she was also incredibly intelligent, fierce, charming, articulate, creative and talented.
When we butted heads, we fought ferociously, but when for the most part we got along, we cared for each other, laughed with each other, and had moments of great depth and connection. I’m not a RN or a doctor. I can’t imagine how difficult those jobs are, particularly in mental health wards. I worked with young people with suicidal intent, and I know it’s a constant battle, and tragically a fair bit of luck to keep them alive, and I know how difficult it could be to talk to Mum, connect with her, reason with her, when she didn’t want you to. I don’t blame anyone individually, but it hurts so much to think that Mum might have been treated coldly, ignored, or felt uncared for in those last days. It also hurt not to be able to say goodbye.
She asked for us not to visit, and I respected that, but if I’d known I wouldn’t see her again, talk to her again, I would have done things differently. I expected that at least in the hospital she would be safe until we could help her again. I just hope that we can learn from this and recognise the deep changes needed in the way we support mentally ill people. My Mum had a lot of issues, but suicide is a horrible, heart-wrenching end to a life and a hospital is the last place it should happen. The last three years of me coming to terms with both losing my Mum in this way and having the constant reminder of hearing dates being scheduled and rescheduled, which comes with little details being revealed about my Mum’s last days, that are new distressing images to dwell over.
The importance of bringing to light injustices and holding systems accountable is crucial.
But the pain it causes those affected mean the process cannot be taken lightly and cannot be ignored once problems are exposed. If issues had been remedied after the first person took their life in distress and loneliness while they were in the one place most equipped to care for them. Three more might be alive today, including my Mum. If that isn’t cause for change, I don’t know what is.”6 6 Transcript of proceedings dated 20 April 2018 (p 3 – 6).
Ms Fisher was in the emergency mental health unit awaiting a bed at AMHU. It was the family’s view that the wait to get into the AMHU was tragic for her.
The family believed and expected, that their mother should have been safe after being admitted for an attempted suicide. They considered the unit where she had been admitted to, was completely inadequate for their mother’s care. The family stated that they were concerned about the lack of care that their mother received. The family did not blame the RNs, because they were of the view that the staff all seemed exhausted.
The family was shocked to think that she had two dressing gowns which had been left for her with belts attached and had not been examined and cleared or checked for potential ligatures. The family said if they had known that the hospital would not check the bags, they would have said something. As a result, the family now feel guilty because it was through them that she had the means to commit suicide.
The family stated that Ms Fisher’s life had been ruined by the parish priest Patrick Cusack and the Catholic Church, who knew about his proclivities and continued to give him unfettered access to children which included Nicola Fisher. Ms Fisher was sexually abused by him when she was only six or seven years of age and it had a lasting impact on her life.
Constable Best
Constable Best indicated that Police were advised of Ms Fisher’s death on 20 March 2015 at 10:17 hours. The death had occurred at 09:45 hours in the Medical Health Assessment Unit. (MHAU)
Constable Best was told that Ms Fisher was a voluntary patient. She was also advised that RN Matsika had found her hanging from the ensuite door. Police collected a blue dressing gown with a matching belt.
Constable Best was told that Dr Wood saw Ms Fisher at 08:40 hours. She was advised that RN Matsika said he saw her alive at 09:00 hours and at 09:39 hours, a medical emergency was called. RN Matsika and wardsman Archer was present when the Medical Emergency Team (MET) arrived.
Constable Best said that she was advised that when the MET arrived headed by Dr Cole, Ms Fisher was already centrally cold, peripherally cold, her pupils were fixed and dilated and there were early signs of lividity in the lower limbs and torso.
It appeared from that evidence that it had been 40 minutes since Dr Wood, or anyone had seen Ms Fisher alive. Mr Archer told Constable Best that he had been told she had not been seen for one hour prior to discovery. Mr Archer did not recall who told him that.7
Constable Best commented about her difficulty in interviewing staff. Constable Best said that she asked and was attempting to organise for hospital staff who had been present at the incident to participate in a Record of Conversation with Police soon after the death. She was advised that the staff would not be providing a statement to Police 7 Transcript of proceedings dated 20 April 2018 (p 28).
on this date, and that she could organise this at a later date through the medicolegal coordinator for mental health staff and Jenny Broom for health staff.8
Constable Best advised Debbie Plant and Fiona Keddie that Police needed to speak with certain staff members immediately to obtain information to complete the report for the Coroner. Constable Best said that she was advised staff would not be providing statements or records of conversation with Police on that day. However, was told Police could speak to the staff and senior staff member present if the staff member agreed to do so.
The staff members present during the incident were Dr Sarah Wood, Registrar Leone Harvey-Smith, RN Clements Matsika, RN Russell Robson, wardsman Cody and Tessa Seeley.
Constable Best was also advised that some staff members present at the time of the incident had gone home for the day and that they would not speak with Police.
Constable Best conduct investigations in relation to Ms Fisher’s history which included that she had been sexually abused by the local parish priest in Queensland, a Father Patrick Cusack. After 19 years he was exposed by the media. It was at that time that Ms Fisher disclosed that she had been abused by him. At a later time, she was compensated in that regard. It appears Ms Fisher for most of her life suffered as a result of that abuse.
Ms Fisher was an intelligent woman who had several children, two of whom lived with her prior to her death. It appears that Ms Fisher had an altercation with one of her sons, which ultimately ended with her assaulting him and he then left home. Family members attended and ultimately contacted the Crisis Assessment Treatment Team (CATT) as they were concerned that she may have taken an overdose of her medication. Family members located a note on a table that had been written by Ms Fisher which included a list of pros and cons of killing herself. The Crisis Team eventually arrived and became aware that Ms Fisher had cut herself, an ambulance was called, and she was conveyed to the hospital.
On 19 March 2015, two of her family members, Melanie and Rowley, attended the hospital and left a new dressing gown and slippers for Ms Fisher. Ms Fisher did not want to see them, so they left the items with staff. The dressing gown had a belt attached to it.
The family said that they received a telephone call on 20 March from a psychiatrist representing Dr Norrie, who advised them that Ms Fisher had hanged herself.
Constable Best said her investigation focused on particular issues including, was there adequate supervision and monitoring of Ms Fisher by the staff and were the staffing levels in place at the time of the death appropriate.
Constable Best provided Ms Broome and Ms Hemming with a list of issues and questions in order to prepare staff statements for the inquest. Constable Best also identified statements that she had received from Ms Broom and Ms Hemming.
8 Transcript of proceedings dated 20 April 2018 (p 59-68).
Constable Best also provided the suicide note, which was given to her by ACT Health and which was exhibited as Exhibit 57 in the proceeding. That note had been found at Ms Fisher’s residence and brought into the hospital.
Constable Best opined that, after extensive enquiry, she could find no evidence of any third-party involvement in the death of Ms Fisher. Constable Best identified that the ‘At risk” ARC checks were conducted every 30 minutes on the deceased, as required with the exception of the last recording, being a 15-minute check at 09:15 hours on the morning of her death. This check was recorded as the deceased being seen on the couch by a RN Matsika. The 09.00 hours check recorded that Ms Fisher was in the bathroom and was not physically seen by the staff members conducting the check.
Constable Best opined that she had concerns in relation to the evidence regarding the ARC checks. Constable Best said every check was conducted on the half-hour, in every check Ms Fisher was recorded as resting in bed. Constable Best examined all of the observations conducted over the three days that the deceased was in the MHAU. The 09.00 check had her in the bathroom which is the first time she was not resting in bed and then the check done on a 15-minute mark which is at 09.15 hours stating she was on the couch. Constable Best noted that on the 09.00 hours check she was not seen or spoken to by RN Robson who was conducting the ARC check.
Constable Best said that staff attending the MET call were told that she had been seen half an hour before and one hour before being found. When those staff were asked questions about when she was last seen, there was no mental health staff present in the room as CPR continued.
Constable Best said that she had been unable to identify what items patients could safely have with them on the ward, noting that Ms Fisher had a dressing gown with a cord attached to it which she ultimately used as a ligature to hang herself. Constable Best observed that the ensuite in room 5 of the MHAU was capable of being locked from the inside. A screwdriver was required to unlock the door to gain access to Ms Fisher. Constable Best opined that this was suboptimal and clearly posed a risk to patients who were at risk of suicide.
Constable Best also provided information in relation to mental health assessments conducted in the MHAU by clinicians. The clinician who conducted the assessment stated that it was a standard assessment, which is relatively quick compared to a more detailed assessment, which would be conducted in the inpatient facility such as AMHU.
Constable Best opined that given the deceased’s withdrawn behaviour, her lack of fluid intake and food consumption over two days, given those factors Ms Fisher’s voluntary status should have reassessed.
Constable Best also identified the current standard operating procedure in place surrounding removal of personal property from patients against their will. It was apparent that MHAU staff did not believed they had any power to remove any personal property against patient’s will. Constable Best opined that when patients are admitted with mental health issues into the care of AMHU, whether they are voluntary or not, items such as belts or dressing gown ties should be removed to ensure the safety of the patient as well as the safety of others.
Constable Best identified that the changes already implemented by MHAU since Ms Fisher’s death, alongside completion of the new model of care and the new Mental
Health Short Stay Unit, would hopefully ensure the safety and wellbeing for all future patients and reduce the chance of another suicide in an ACT Health facility.
It was suggested to Constable Best that she was told that hospital staff were extremely upset, and she was asked if were possible for her to come back on another day to take the statements, rather than a refusal to allow access to staff on the day. Constable Best disagreed with that suggestion.
Constable Best agreed that she had received, from Ms Broome, a request for a list of questions to assist the staff in compiling their statements. Constable Best also agreed that she had extended the time frame for those statements to be provided until the 16th of May 2015 and they were provided on 20 May 2015. All outstanding statements were provided by August 2015.
It was suggested to Constable Best, that the provision of the statements, within that timeframe, after those questions were supplied, was an efficient way of obtaining evidence from the witnesses. Constable Best disagreed with that proposition.
Constable Best said Police have more experience generally with taking statements, and in knowing what information people can give, if they are able to speak with them initially and review the information they have. As a consequence, those persons may not be required to give a statement at all after the initial investigation is conducted.
Constable Best said not knowing what information people have and what involvement they had in the matter, probably resulted in more statements being taken than was required. Constable Best said there are some statements that she read, that had she known what they had to say, may not have been required in this matter.
It was suggested to Constable Best that she did not request access to the witnesses.
Constable Best said that she did not know that she could do so because she was told she had to go through Medicolegal.
Constable Best said that, in her view, it would have been best practice to have spoken to those witnesses who were the last to see Ms Fisher alive and those who found her deceased, at a minimum. Constable Best agreed that those staff members may well have been distraught but that occurs in many situations when Police turn up to a death.
Constable Best agreed that there is no requirement for witnesses to participate in Police interviews. However, she said that if that was the case that they refused to speak with Police, she would report that immediately to the coroner.
Constable Best agreed if they were distraught and did not want to speak with Police, then the next best thing was to receive a statement at a later date.
I made the comment that if witnesses are not prepared to give material evidence at the time, then the matter could be set down at short notice for the coroner to have that information elicited.
I also questioned Constable Best in relation to her training as an investigator. Constable Best told me she was a detective trained to investigate matters and she often deals with people who have suffered trauma. Constable Best said it was her view and her experience that despite having suffered trauma, people are usually willing to speak with Police. It is her experience that generally witnesses will speak to Police either that day or the next.
Constable Best agreed that a Police officer had spoken to RN Matsika that day, after a delay.
Dr Edirimuni Rodrigo
Dr Rodrigo is a qualified psychiatrist who assessed Ms Fisher. It was his view that Ms Fisher had suffered from a situational crisis. However, upon further review had changed his opinion, after speaking with family who told him about a written suicide note and the fact that she had also cut herself in an attempt to commit suicide.
Dr Rodrigo indicated that if Ms Fisher had been admitted to the AMHU he would have conducted a more comprehensive assessment of her, as well as examining her several more times. Dr Rodrigo said he would have contacted her general practitioner as well.
Dr Roderigo stated that his assessment of her in the ED was not a detailed assessment but was sufficiently detailed to make the decision he made. Prior to examining her he had access to her notes and noted that she had not had any treatment since 2007 by Mental Health. After considering the notes, speaking with the family and examining the patient, Dr Roderigo diagnosed her with severe depression with suicidal intent.
Dr Roderigo concluded that Ms Fisher was not at risk of imminent suicide given that she was working, had not had any dealings with Mental Health since 2007. Dr Rodrigo noted it was in a situational crisis because of the altercation with her 14-year-old son and during that period since 2007, there had been no suicide attempts. Dr Roderigo said he did know that she had written a suicide note but she had made no specific plans, as well as the fact that she was in a ‘safe place’.9
Dr Rodrigo knew she had written a suicide note, was aware that she is still felt suicidal and concluded she was at medium risk given she did not have a plan to commit suicide.
Dr Roderigo planned to admit her, ordered she was to be observed every 30 minutes and considered she did not need a special to be with her full-time.
Dr Rodrigo suggested that it was unusual that Ms Fisher had to wait so long for a bed at the AMHU. Dr Roderigo said that he did not review her on 19 March because she was bed booked for the AHMU, and unless he is told that there is a need for further review, patients don’t get reviewed because she was to be admitted to the Unit.
Dr Roderigo opined that it is difficult to make a prediction in relation to suicide. Despite categorisation and assessment, it is extremely difficult even for experienced psychiatrists to predict an outcome and many times they have been proved to be wrong.
Dr Roderigo agreed that at the new Mental Health Short Stay Unit, assessments are conducted in more detail and treatment is commenced because they are part of the treatment model, which is a change from the old model.
In respect to checking patients belongings, it was his understanding that if the patient was voluntary the RN is required to obtain consent and explain why they need to go through the belongings, explaining that the reason is to ensure that there are no dangerous items such as belts or cords. It was his view that Ms Fisher should not have had the belt with her.
9 Transcript of proceedings date 1 May 2018 (p11.40).
Dr Roderigo explained that the reason Ms Fisher had to wait for a bed at the AMHU was because another patient had priority.
In cross-examination, Dr Roderigo said it was his recollection that Ms Fisher was wearing pants and a blouse but was willing to accept that she was in fact wearing a dressing gown. Dr Roderigo said that if he had seen her with a dressing gown belt, he would have suggested its removal.
During the course of Ms Fisher’s stay, Dr Roderigo agreed his impression about her situational crisis changed because she did not get better. Dr Roderigo agreed that he did not do a fulsome assessment upon her despite that change, agreeing that despite the fact she had not eaten any food, or fluids, and was refusing medication, he did not consider placing her on an involuntary order.
In terms of risk assessment tools, Dr Roderigo was of the view that they are dangerous clinically because they cannot predict a particular risk and patients can still suicide despite the risk categorisation. Dr Roderigo said that it is better to have a prepared clinical management plan.
The best outcome would have been for Ms Fisher to be admitted to the AHMU as soon as possible. Dr Roderigo agreed that there is usually insufficient time to do a review of patients because usually they are in the Unit for such a short period of time. Dr Rodrigo did not do an assessment review despite her being in the Unit longer than usual.
Dr Roderigo stated that there is a change in the Unit now, and that if there is a bed booked and the patient is still in the Unit, they should be reviewed daily. That change came about as a direct result of Ms Fisher’s death and the Mental Health Short Stay Unit is now in place and the model of care has changed.
In answer to questions from me, Dr Roderigo agreed that in the Mental Health Units’ patients are required to remove belts as a safety factor. It has nothing to do with being voluntary because the item may be used as a ligature of some sort. Dr Roderigo said this applies in the Short Stay Unit as well. Dr Roderigo opined that the belts should have been removed and the failure to remove the belt must’ve been an oversight.
Dr Roderigo suggested in relation to recommendations for the Coroner, that the bed ratios in the ACT are almost half the national level. That is important considering the hospital accept patients from surrounding New South Wales. Dr Roderigo opined that without addressing that issue, the service will always have chronic problems of bed block. Dr Roderigo also stated that it is difficult to get staff and they have been recruiting internationally in order to do so.
Dr Roderigo stated that after serving 41 years in psychiatry he had to take two months of stress leave last year because he was burning out. Dr Roderigo stated that it is not only the doctors but also the nursing staff who have the same issues of stress and burnout.
Dr Roderigo stated this is a worldwide situation not just a problem for the ACT in terms of recruitment.
Russell Peter Robson
Mr Robson is a trained RN with a postgraduate diploma in mental health nursing. He is also trained in intensive care and emergency nursing.
On 18 March, he was conducting ARC observations of all patients on the Ward. At that point Ms Fisher had not been allocated to any RN and was being team nursed. Team nursing is where all RNs look after all patients together, no one was responsible for any patient in particular.
RN Robson said that every time he saw Ms Fisher, she was laying on the bed, except for one occasion when she was speaking to a doctor and was sitting on the couch.
RN Robson could not recall what she was wearing. RN Robson said that on admission patients should have been asked about whether they have any belts or something dangerous, such as alcohol, or anything that could be a danger to either the patient or someone else. At the time of Ms Fisher’s death there was a requirement to check the patient’s belongings for dangerous items on their admission.
RN Robson said that with his experience now and hindsight he would have asked her for the belt, but he could not recall whether she was wearing it as she was always lying on the bed.
RN Robson performed the ARC observations at 08.00 hours and noted that she was resting in bed. He also performed the ARC observations at 09.00 hours. He accepted that the 08.30 observations were not filled in on the ARC observation sheet, but he said that he performed the observation at 08.30 because there were no notes to indicate that he had not done the observation.
RN Robson said that he did the check at 09.00 but did not check the bathroom or anywhere else for that matter because he assumed she was in the bathroom. He did not enquire as to whether she was there. RN Robson said that was because of the issue of privacy.
I asked RN Robson about the object of the exercise and I made the comment that the reason for the observations was to ensure that the patient was safe. RN Robson said that it was acceptable to come back some five or 10 minutes later to check on a patient.
However, that appears not been done by him in Ms Fisher’s case.
In cross examination it was raised that the observation form made it clear that the observations were to be randomised. Yet, the observations conducted on Ms Fisher were done every 30 minutes on the half-hour. RN Robson said it was difficult to randomise half hourly observations. Mr Robson admitted that he did not see that observations were to be randomised on the top of the form, despite being in bold print.
RN Robson accepted that a patient would be able to tell how long it was to the next observation which is the reason for the practice of randomising the times. However, he said that the practice was to do it every 30 minutes, despite the clear instruction on the observation sheet.
RN Robson stated that he did not go into room five at all and merely looked through the windows, he said he did see that the bathroom door was shut. I noted that he should also actually have sighted the patient as well not just assumed that they were there which is the object of exercise.
RN Robson agreed that effectively he did not read the form, which I note is emboldened with the words randomise observations.
RN Robson stated that he did not have a practice of pre-filling in the times of the observations and did it at the time he was making those observations. He did not pre47
fill the 08:30 time he said he did that at 09.00 and left it blank because it had not been done.
Mr Robson said he had not recall telling anyone he had done the ARC observation at 09:00 hours or that he had not seen Ms Fisher, but he said it was his practice to do so.
The only notes he made were on the MHAGIC system. The nurse to patient staffing ratio on the day was 3 RNs to 5 patients.
Clemence Matsika
RN Matsika is a Registered RN and has been since 2007. He specialises in mental health nursing.
On 20 March, he attended a hand over and was allocated Ms Fisher as a patient. He was aware that Ms Fisher was not eating and drinking and that was a concern.
RN Matsika was not responsible for the ARC observations on Ms Fisher, but he was allocated to attend to her. He said he went to give her the morning medication she was prescribed. RN Matsika said that he asked her whether she would like to eat or drink anything, and she told him she did not. RN Matsika knew that she had not had anything to eat the day before.
RN Matsika said he gave her the prescribed medications and advised her that she would be going to the AMHU as soon as a bed was available, and that would occur probably sometime that day. RN Matsika said he thought she put the tablets in her mouth but did not take any water and declined the offer of water. RN Matsika was concerned that she had not swallowed the tablets and thought she may have been hiding them in the bed linen.
RN Matsika asked whether he could change her bed linen and when he did so he could not find any tablets, although he noted she had her fist closed.
RN Matsika said that he noticed that she had a blue dressing gown on but can’t remember whether it had a belt on it. He said that if he had seen a belt, he would have removed it. RN Matsika stated that patients have their belongings checked as a matter of practice and if a belt had been seen it would have been taken from her. RN Matsika accepted that she did have a belt with her and said the staff were professionals and he expected that they would have checked her belongings for items such as a belt.
RN Matsika said he repeated his observations of Ms Fisher, particularly in relation to her blood pressure and the like. RN Matsika reported his findings to RN Lanfranchi and Dr Wood. RN Matsika said that he was concerned for her because she hadn’t been eating and drinking and with her behaviour, he was worried that she needed a further assessment which Dr Wood undertook.
RN Matsika said that he did not attend Ms Fisher with Dr Wood, but he said he did check her at 09:15 hours and made a note of it in the clinical ARC. RN Matsika said he saw her through the observation window, and she was sitting on the couch.
RN Matsika said that it could have been 09:35 hours rather than 09:40 hours when he found her in the bathroom. That is a timeframe of 20 minutes for her to hang herself, die and become centrally and peripherally cold.
Upon reflection, RN Matsika said that the MET arrived at 09:40 hours so he must have checked her about 09:35 hours. He could not be precise in relation to that issue.
RN Matsika said he called Ms Fisher’s name and there was no response. He says at that point he then went to the RNs station to get a female staff member to come with him. He said he then had to use a screwdriver to unlock the door. RN Matsika says he then put his fingers in between her neck and the ligature to try and assist her breathing.
He said that he used the emergency device he had in his hand to call for the MET.
I note that the MET team arrived at 09:40 hours, RN Matsika said the ligature was cut off but that did not take much time. Upon questioning he disagreed that Ms Fisher had last been seen at 09:00 hours.
RN Matsika agreed he had opened the MHAGIC notes at 08:42 hours not 07:40 hours.
RN Matsika agreed that he did brief Dr Wood at approximately 08:30 hours.
RN Matsika said he spent the entire time from 07:40 hours to 08:30 hours with Ms Fisher. RN Matsika did not remember anyone coming in to do any observations upon her. When it was suggested that RN Robson completed the 08:00 hours observations and there was no one with Ms Fisher at the time, RN Matsika said that he may have been going to get her medications at that point.
RN Matsika denied speaking with any of the MET team and telling them that the last time someone observed Ms Fisher was 09:00 hours. It was suggested to him that Dr Cole wrote in a note, a very short period of time after the MET call that the patient had last been seen by Dr Wood at 08:40 hours. Dr Cole advised that RN Matsika told him that he saw Ms Fisher last at 09:00 hours that morning.
RN Matsika denied having a conversation with Dr Cole. He said he did not say that to Dr Cole because he saw Ms Fisher at 09:15 hours and was adamant that he did not tell Dr Cole that it was at 09:00 hours.
It was suggested to RN Matsika that the entry of 09:15 hours was done later and that he did not see her at that time, he denied that.
RN Matsika agreed that he had not written anything in the MHAGIC notes about his observations of Ms Fisher at 09:15 hours despite the portal being open. RN Matsika advised that there were only three computers for about seven people, and they were not always available to use straight away.
It was suggested to RN Matsika that the MHAGIC notes were open at the time and the only place for noting the observation was the ARC observation form. Further, it was not his job to do the ARC observations on Ms Fisher at that point in time.
It was suggested to RN Matsika that he had not made a note in MHAGIC until 16:00 hours that day. RN Matsika agreed with that proposition.
It was further suggested to RN Matsika that he did not do an ARC check on Ms Fisher at 09:15 hours and that he put that entry onto the ARC observation form after Ms Fisher’s death. RN Matsika denied that.
It was suggested to RN Matsika the Dr Cole made a note of the conversation with him at 09:50, very shortly after the event, that Ms Fisher was last seen at 09:00 hours. RN Matsika said he did do the check at 09:15 hours
I note RN Matsika said that when the MET team arrived, he did not participate in the resuscitation effort and went back to the office.
Christopher Cole
Dr Cole is an emergency specialist who was employed at TCH when Ms Fisher was admitted.
Dr Cole responded to a medical emergency request at the MHAU on 20 March 2015 at approximately 9:40 am. Dr Cole stated that he jogged to the Unit which took less than 30 seconds.
Dr Cole described finding Ms Fisher lying on the floor with a belt around her neck and RN Matsika trying to relieve the pressure of the ligature around her neck. Shane Archer, a wardsman was attending to the CPR. Dr Cole attended to her airway and examined her noting her tone was globally flaccid. More medical staff arrived, and CPR was continued. Dr Cole observed no clinical output and no spontaneous respiratory effect.
Dr Cole indicated that he asked how long she had been hanging for as that would have been one of the first things he asked. At the time of his evidence, he could not recall the information that he was given. Death was recorded at 09:43 hours.
Dr Cole made a note written at 09:50 hours. Dr Cole stated that it was RN Matsika who told him that Dr Wood saw Ms Fisher at around 08:40 hours. However, in his evidence before me he now says he cannot recall and was not sure whether it was RN Matsika who told him that information.
Dr Cole also indicated that it was his understanding that Ms Fisher had not been seen for some 40 or 45 minutes which placed the observations that she was last seen around 09:00 and that was the basis of his assumption. It was also an assumption that it was RN Matsika who was the last person to see her, but he cannot recall who gave him that information.
In cross examination, Dr Cole considered that he had a fair memory of what happened.
However, he did not recall whether his assumptions were based on information from RN Matsika or whether someone else had informed him of the time she was last seen.
I note that Dr Cole wrote in the medical notes at 09.50 hours that “last seen alive at 09.00 40 minutes before MET call”
Dr Cole accepted that he had been more descriptive in his recorded conversation with Police as to how Ms Fisher was found. Noting that she had being peripherally and centrally poorly perfused and cold to touch in both her peripheries and her core. He agreed that is different to the descriptive detail that he wrote in his statement made in
Ultimately, he said it meant the same thing.
Dr Cole accepted that he had told Police some two hours after the event that scissors were used to cut the ligature from her neck. Dr Cole agreed that he pronounced death at 09:43 hours. It was after approximately 10 to 15 minutes that Ms Fisher was moved onto her bed. Dr Cole stated that ultimately, after some discussion about whether to move her or not for forensic purposes, he made the decision to move her. The reason was mostly because he wished to preserve her dignity.
Dr Cole had stated to the Police that he was told that the last time someone saw Ms Fisher was 09:00 hours. In his statement made in 2018, he reflected that it was most
likely a calculation not a specific time. He indicated that there was some times bandied around by the staff and considered the time was based on a calculation that he made rather than being told the actual time.10
Dr Cole accepted that his memory would be better at the time of the incident and he may well have been mis-recollecting the evidence he was giving before me, but he thought that was unlikely. In answer to questions from me he accepted that he could not now say one way the other.
It was put to Dr Cole that he had provided a statement three weeks prior to giving his evidence in which he stated that it was RN Matsika who told him that Dr Wood had seen Ms Fisher at approximately 08:40 hours that morning. Dr Cole agreed that his recollection is now different and said that at that time timing was not important to him.
I found his evidence to be difficult to understand in that regard and I question his memory given the length of time between Ms Fishers’ death and him giving a statement to ACT Government Solicitors and ultimately giving evidence before me. I prefer the evidence of the medical notes he wrote and the conversation he had with Police very shortly after the incident.
Dr Cole was questioned about his answers to questions from Police regarding procedural issues and possible breakdown of those procedures. Dr Cole indicated that ultimately, he did not have any specific concerns about any deficiencies in MHAU.
Dr Sarah Wood
Dr Wood was a junior medical officer at The Canberra Hospital in 2015. In March 2015, Dr Wood commenced a block rotation on 16 March. This was her first rotation to the MHAU. It was her duty to assess patients and report her findings to the psychiatric staff.
Dr Wood said that on the morning of 20 March 2015, she was aware that Ms Fisher was not eating or drinking. She does not recall who advised her but there were several staff in the Unit including Dr Harvey-Smith, RN Lanfranchi and RN Matsika.
Dr Wood said she assessed Ms Fisher who was in room five. At the time she was on her own. Dr Wood said that it was her usual practice to write the time of the assessment at the time of the assessment and that was at 08:40 hours. Dr Wood opined that it could have taken between 10 and 20 minutes for the assessment to take place. In her note she wrote that Mr Fisher’s affect was quite flat, and she seemed depressed. After conducting clinical observations including blood pressure, Dr Wood decided Ms Fisher did not require intravenous infusion and she did not indicate levels of dehydration that were dangerous. It was her view that oral fluid would be sufficient to hydrate Ms Fisher.
Dr Wood said that Ms Fisher indicated that she may think about taking some oral fluid.
Dr Wood said that she went to find some fluids to give to Ms Fisher and when she came back to her room, she saw Ms Fisher entering the bathroom. Dr Wood only recalls that she saw Ms Fisher going into the bathroom and closing the door. She did not say anything to Ms Fisher at the time.
Dr Wood said that it was approximately 09:30 hours when she heard the duress alarm sound. The duress alarm is quite loud so that everyone could hear it.
10 Transcript of proceedings dated 15 September 2018 (p 175).
Tessa Seeley
Dr Leonie Harvey-Smith
Dr Harvey-Smith gave evidence before me on 3 September 2018. In 2015 she worked as a Registrar of psychiatry in the MHAU. Dr Harvey-Smith worked regularly with Dr Roderigo.
It was Dr Harvey-Smith’s practice that she and Dr Roderigo would together review patients in the Unit each day. Dr Harvey-Smith indicated that she did not review Ms Fisher with Dr Roderigo because of the number of patients on the Unit to be seen. It was not always possible to review all the patients with Dr Roderigo.
Dr Harvey-Smith explained that although it was only a six bedded Unit on one day, she walked in and found there were 23 names on the board of patients to be seen.
Dr Harvey-Smith said she regularly attended for duty at 08:00 hours and was given a handover by the RNs in a multidisciplinary team meeting.
Dr Harvey-Smith said that she did not review Mrs Fisher on 18 March and had not reviewed her notes. Dr Harvey-Smith recalled speaking with Ms Fisher’s daughter and was surprised that she told her she was distressed about being left alone with her mother.
Dr Harvey-Smith, in her statement, referred to a review which was attended by RN Matsika, RN Lanfranchi and RN Robson as well as Dr Wood. Dr Harvey-Smith said that she believed Dr Wood undertook a physical review of Ms Fisher given she was not eating or drinking. Dr Harvey-Smith also indicated that she was concerned that Ms Fisher was isolating herself.
Dr Harvey-Smith recalls that she was concerned that because of Ms Fisher’s limited oral intake, and she may need to discuss intravenous fluids being administered with her colleagues from the Emergency Department.
Dr Harvey-Smith recalls having a conversation with RN Matsika in relation to him having to strip the bed because of a concern she was hiding medication.
Dr Harvey-Smith recalls that she was with a patient when she heard the duress alarm being sounded. Dr Harvey-Smith saw a MET doctor going past her in the hallway toward Nicola Fisher’s room and realised it was a serious situation.
When she arrived in the room, she saw Ms Fisher had blue lips, she was fully clad and was being attended to by the medical emergency team. Dr Harvey-Smith said she waited in the room until medical emergency team called off the resuscitation efforts.
Dr Harvey-Smith said that after the resuscitation had been called off, the staff collected in the RNs station and discussed the morning events, as well as the timing for the ARC review observations. She also stated that they discussed RN Matsika reviewing Ms Fisher only 15 to 20 minutes before she was found deceased and how quickly she must have acted in that time to enable the successful suicide.
Evidence in Relation to Christine Belle Douch Constable Cameron Gordon
Constable Gordon prepared two volumes of material for the coronial inquest.
Constable Gordon also provided a summary of circumstances, which he read onto the record in the proceeding. Constable Gordon gave evidence in relation to his investigation of the death. He advised that Ms Douch suffered from systemic lupus erythematosus (SLE), gastro-oesophageal reflux disorder, fibromyalgia, migraines and lower back pain as well as chest pain, knee pain and narcolepsy.11
Constable Gordon gave evidence that when he arrived at hospital there was no evidence of any disturbance in the foyer of the hospital where Ms Douch fell to her death. There was no sign of the incident at all as it had been cleaned up.
Constable Gordon investigated how the death occurred and stated that it appeared to him, and there was evidence to support the fact, that Ms Douch had climbed over the railing on the third floor and jumped to her death. In order to do so she used for support, a glass cabinet which was near the railing to climb over the balustrade.
Dr Choi, one of the medical staff, saw Ms Douch near the balustrade by herself but thought nothing of it. This was around 21:35 hours. Constable Gordon ascertained that not long after that time at about 21:37 staff heard a loud thud.
Constable Gordon opined that the height of the balustrade was not easily accessible to climb upon. It was made easier by the fact that there were two glass cabinets right up against the balustrade. It appears Ms Douch used them to assist her to climb over the balustrade.
Constable Gordon advised that once the hospital was aware of this issue, changes were made, and the glass cabinets were removed from that area. The hospital, as a risk mitigation strategy, increased the height of the balustrade as well. CCTV cameras were also installed on that level, as well as investigating a proposal that the third-floor level be sealed off to act as a barrier and eliminate the opportunity to jump from that level.
Constable Gordon stated that the focus of the investigation was to gain an understanding about Ms Douch’s physical health and how that impacted her mental health. It was also to focus on the circumstances surrounding the suicidality assessments performed at TCH on patients. The other was how she was able to have free access to an area where it was high enough for her to jump from and whether there had there been any risk assessments of that area previously.
There was also an investigation into the trial of the drug Belimumab (BCB) as Ms Douch was trialling it for her SLE. It was well understood that the drug could cause suicide ideation but there was treatment and plans in place for that circumstance and if she had been feeling that way, she would not have been given the drug.
Constable Gordon said that when Ms Douch had passed the RNs station not long after that they decided to move her to room 16. A suicide note was found in her belongings 11 Transcript of proceedings dated 17 April 2018 (p 8 – 22).
after she had jumped to her death. Constable Gordon obtain CCTV footage of the incident which didn’t really show where she jumped from but did show her falling.
Constable Gordon spoke with Dr Regna who suggested that the deceased indicated to him that she took the overdose because of her significant pain and it was not to end her life. That assertion was backed up by Ms Douch ’s family. As a result of that information Dr Regna discharged her from a mental health perspective. As a result, her one-on-one care was removed. It was at that point she could freely walk around the ward.
That information was in contradiction to what she had told RN Karia. Ms Douch had a long conversation with RN Karia and advised her that she had planned the overdose with the intention of killing herself. That was not relayed to Dr Regna. No psychiatric staff was informed about that conversation. There was no follow-up for a psychiatric review after having that information available.
Constable Gordon made some recommendations in relation to the fact that the information was not referred to the psychiatrist. Constable Gordon recommended that patients admitted for suspected self-harm should have a separate form which is available to all treating personnel which communicates any comments from the patient, any notes or suicide notes that they may have written, and that this should be from the time of admission until discharge. It was his view that the information should be prominent. In my view, that may be the case, but it is also important that staff communicate this type of information in a proper way.
Constable Gordon also accepted that it was prudent to increase the height of the balustrade, employ CCTV cameras and not to have objects close to the balustrade which can be used as a means of climbing onto it. Constable Gordon also made a recommendation in relation to patients taking strong opioid medications suggesting they should use a Webster pack.
The suicide note was not given to the hospital on admission, but they certainly knew about it. I also note that Mrs Douch had attempted suicide in 2001 and her daughter had said she had a history of speaking about suicide and attempting to commit suicide by overdose. There was clearly a history of suicide attempts and that was known at Bombala and was also known to some staff at The Canberra Hospital.
I commend Constable Gordon for his excellent investigation and thorough preparation of the brief.
Professor Cook
Professor Cook ran the Belimumab trial. Mrs Douch was on that trial and had been for some 48 weeks at the time of her admission. The drug was to treat her SLE and had been approved by the FDA in the United States in 2011. For approval in the Australian context, trials needed to be conducted so that the TGA had material in which to approve the drug. I understand that drug is now in use.
Professor Cook described SLE as an autoimmune disorder and that Belimumab reduces the B cells and therefore reduce the symptoms of SLE. The drug is given intravenously, and the patients are reviewed prior to the administration. The most likely side-effect is infection, although there is a known side-effect of suicide ideation.
Professor Cook suggested that assertion was inconclusive but there were some
suggestions it could have an effect because patients with lupus are five times more likely to have risk of suicide ideation.12
Ms Douch was always assessed prior to the administration of the intravenous Belimumab. Ms Douch had no suggestion of suicidality until week 48 of the trial. It was Professor Cook’s view that the administration of the Belimumab was unlikely to be responsible for it. It was his view that the self-harm ideation was probably the result of several factors including the SLE, the increased pain from the arthritis as well as mood disturbances.
Professor Cook was advised the assessment form used for the trial it showed a history that Mrs Douch had no past self-harm which was clearly wrong. Professor Cook opined that that was an important factor but probably not persuasive.
Dr Regna
Dr Regna was, at the time Ms Douch was admitted to TCH, a psychiatric Registrar. He was part of the psychiatric consultation and liaison service which reviewed patients in the hospital who were not under treatment by mental health staff. The service offered a 9 to 5 service, as well as some after-hours coverage which included the ED. This ensured that there was a 24-hour coverage for patents in the general hospital who require mental health assessment. Dr Regna saw Ms Douch in the MAPU otherwise known as ward 7B.
Each morning a multidisciplinary team meeting was held, and it was at one of those meetings that he received a request to see Ms Douch. Dr Regna said that he was advised that Ms Douch had taken an intentional overdose and was not medically cleared at the time. Dr Regna used the MHAGIC system to write his notes. At the time this system was used specifically for the Mental Health Department. It was not available to other staff and there was a requirement to print out the material and fax it to the Ward. As I understand it, this was done in Ms Douch’s case.
Dr Regna said he assessed Ms Douch and she told him she took an accidental overdose because she wanted to stop the pain. Ms Douch’s family backed her up on that assertion. Having fully assessed her and considering those factors, it was his opinion that there was nothing indicating to him that she was a risk of suicide. As far as he was concerned, once she had been medically cleared from the ward she could be discharged. Dr Regna anticipated that would happen on the weekend.
I am unable to ascertain why she lied to Dr Regna and why the family backed up her story, given they knew about the note she had written. Clearly a number of factors and circumstances played against Ms Douch.
Dr Regna said had he known about the suicide attempt, the treatment may have been the same, but it may well have been different. Dr Regna said it is most likely she would have been detained involuntarily and/or given one-on-one nursing care. Dr Regna said, with the benefit of hindsight, if the Emergency Department continuation sheet was in the folder when he looked at it, he would have brought that up with Ms Douch, notwithstanding that the outcome of that conversation could not be predicted.
Dr Regna was asked about the recommendation made by Constable Gordon in relation to a document which would stand out with that information upon it. Dr Regna agreed 12 Transcript of proceedings dated 8 April 2018 (p 89).
but said that it needs to stand out, but it will also compete with other important material as well.
Dr Swaminathan
Dr Swaminathan gave evidence that he was the Director of the Unit. He said it was a short stay unit and the ward had a median stay of three days. He noted Ms Douch had been there for six days and that wasn’t unusual.
The Unit had six staff specialists and several registrars. It also had resident medical offices, interns and a full complement of nursing staff as well. Dr Swaminathan was the on-call specialist when Mrs Douch was admitted. It was his view that given the significant symptoms of multi-organ dysfunction, she had taken a significant overdose and in that setting one presumed it was with suicidal intent without more.
Mrs Douch was treated for her condition and was placed on an increased care supervision request because of her overdose. The purpose of that was for safeguarding the patient until further assessment could be made. This was a routine matter and a special RN one-on-one with the patient could have been requested.
Dr Swaminathan stated that Mrs Douch told him that the reason she overdosed was because of her intractable pain. He also recalled that Mr Douch and one of the daughters was present at the same time she made that comment.
Dr Swaminathan gave evidence in relation to the treatment he administered for her critical kidney and renal failure as well as some cardiac issues. Dr Swaminathan also reviewed the notes in relation to a psychiatric assessment and was aware that she denied current thoughts of self-harm and the one-on-one nursing was withdrawn.
Dr Swaminathan give evidence that Ms Douch was prescribed some pain relief but was not able to be given significant amounts because of her condition. Dr Swaminathan, having reviewed the notes, was aware she had at times new pain events. He also knew that it was her birthday coming up and it was a positive sign that she was forwardthinking.
Dr Swaminathan did not consider discharging her over the weekend back to Bombala hospital, because they did not have the appropriate facilities, so she was to stay in Canberra over the weekend.
Dr Swaminathan was asked about the notes made by RN Karia which he had clearly read. Dr Swaminathan said, when asked if he was critical of RN Karia for not including some information in the note; “I think RN Karia has done she has obviously shown her you know, a lot of compassion and kindness, spending this amount of time with a patient on a busy night shift. To spend an hour with the patient to hear their story is very commendable. She has also taken the time to write the note and to alert the appropriate people in terms of handing over of her concerns. The note itself – this is based on her statement rather than the clinical note – is reassuring in parts but I agree that there is some information here that isn’t in the clinical note, but I don’t know it would have made any material difference to, you know, subsequent events or subsequent management. Parts of this statement are consistent with her future thinking, sort of her future planning, in particular related to trying to remain positive, that she could, if she wanted to, take an overdose at home but she wouldn’t do that because of the effects on family. So it may be in retrospect after the events that have happened, reflecting on that, these additional pieces of information
have come out but certainly she has written the – she has written some very pertinent points in her clinical notes and enough for us to pick up on those things and to be alert that she was more agitated and upset that night that she had been or had expressed in the previous few days. So, I’m not critical of RN Karia”13 Dr Swaminathan further stated: “I don’t necessarily think that based on RN Karia’s note, would have subsequently meant for an automatic referral for another psychiatric opinion.”14
Dr Swaminathan also said “so suicide risk can change over time. It can change on a day to day basis, it can change over weeks, months, and so we always need to be alert to that. Certainly if Ms Douch had expressed to any staff, not just to RN Karia overnight, that she had ongoing selfharm ideation or suicidal ideation, then we wouldn’t have relied on that initial psychiatric assessment to say, well, she’s been cleared and therefore doesn’t need another assessment. We routinely would ask for a further assessment if this was to happen on any patient that comes in. That wasn’t the circumstances in this instance though. The circumstances that we were dealing with was an acute withdrawal episode later in her admission rather than an acute psychiatric change, in our view at the time.”15
Dr Swaminathan went on to further state, when asked a question in relation to withdrawal and whether that would increase her factor of suicidal risk, that “it could potentially contribute to that, but focus is really about managing the physical manifestations of withdrawal.”16 Dr Pate
Dr Pate was Ms Douch’s general practitioner at the time of her death. Dr Pate indicated that she was the most challenging pain patient he had ever treated. Dr Pate indicated that he did not know of a previous suicide attempt. Dr Pate indicated that when he treated her, she had a flat affect.
It was Dr Pate’s view that there was a lack of resources at the pain clinic. It was his experience that generally it takes at least 12 months to get an appointment to be seen.
It was his view that there needs to be attention focused on resources for the pain management clinic.
Dr Soh
Dr Soh was a consultant with the alcohol and drug service and was referred by the treating team to see Ms Douch. Dr Soh’s role was not to treat the patients but to give recommendations for treatment in relation to any alcohol and drug issues. The services were available between the hours of 08:00 and 17:30, with a consultant on call 24 hours per day, 7 days per week. A RN was available till 19:00 weekdays.
In answer to a question about what types of complex opioid issues the service routinely would be consulted on Dr Soh said “so we are often consulted where there has been a history of opioid use of significant doses, of high doses, and particularly where there have been problems where a patient 13 Transcript of proceedings date 19 April 2018 (p 174).
14 Transcript of proceedings dated 19 April 2018 (p 176).
15 Transcript of proceedings dated 19 April 2018 (p 184).
16 Transcript of proceedings.
stays in the community before they have entered the hospital. Where also often consulted where there is concerns that there is an element of opioid withdrawal. We are also consulted to assess whether we believe that opioid addiction forms part and parcel of the patient’s presentation.”17
Dr Soh first saw Ms Douch on 4 July 2016. Dr Soh reviewed her because she had overdosed her prescription medication. As a result of that overdose Ms Douch developed multi-organ failure and cardiac issues including a long QT syndrome. Ms Douch was primarily being treated for that condition when Dr Soh was asked to review her.
Dr Soh was ultimately asked to consider whether Mrs Douch was addicted to opioids or whether she was dependent on them. Suboxone therapy was discussed with Ms Douch, who was not keen on that treatment.
Ultimately, Dr Soh opined that Suboxone was not an appropriate treatment option for Ms Douch because she was dependent, as opposed to addicted to opioids. In Ms Douch’s case she was taking opioids for pain relief. It was Dr Soh’s opinion that Suboxone was not suitable for her condition because it did not give her the pain relief she required.
In Dr Soh’s opinion, it was not until the second review of Mrs Douch that it was observed she was in withdrawal from opiates. This is because it can take up to 30 hours for the methadone that she had been on to leave her system and therefore withdrawal of it can be slow.
In order to quell her pain Mrs Douch was prescribed Targin and Oxycodone. It was Dr Soh’s plan that by giving Targin, a long acting opioid as well as Oxycodone a short acting opioid that combination would reduce her withdrawal symptoms and likewise reduce her pain.
Caitlyn Shepherd
Nurse Shepherd was rostered on the afternoon shift to look after Ms Douch. She had referred her to the medical practitioner on the ward, for review of her pain. The medical practitioner Dr Nathan, advise that the medical regime that she had been prescribed must be observed.
Nurse Shepherd indicated that Ms Douch was in significant pain and walked around the ward to assist in relieving her pain. She was also offered a heat pack to assist in her pain management.
The pain Ms Douch complained of was in her feet, which was unusual. Nurse Shepherd conducted neurological testing. Ms Douch wanted to walk around the ward and Nurse Shepherd indicated that she may do so but must keep within the ward. Nurse Shepherd said that Ms Douch indicated she would go to the patient lounge which was on the ward.
It was Nurse Shepherd’s recollection that she introduced her patient to the RN that was going to look after her on the night shift as she was going to get cup of tea or coffee.
Nurse Shepherd continued to hand over to the night shift.
17 Transcript of proceedings dated 19 April 2018 (p 204).
Nurse Shepherd was of the view that Ms Douch appeared to be withdrawn rather than upset.
In cross examination, Nurse Shepherd indicated that she was an enrolled Nurse who had had no specific training in mental health or what to look for in relation to any escalating symptoms of that kind. Since the death of Ms Douch, Nurse Shepherd has had training in relation to spotting suicidality, and mental health first aid.
In relation to recommendations that Nurse Shepard considered might be of value to the Coroner she opined that better staffing numbers were needed to monitor high risk patients. It was also her view that if they had locked down facilities for psychiatric patients or patients who suffer chronic pain and have suicidal ideation that would reduce the risk.
RN Karia
RN Karia worked on the MAPU in July 2016. She was a registered nurse and worked the night shift as the team leader. RN Karia had spoken to Mrs Douch and had assisted in the removal of sutures from her scalp. RN Karia indicated that that point Ms Douch was calm.
Ms Douch was moved to room 8 as it was less traffic and quieter. On 3 July, RN Karia was again team leader, and Mrs Douch was her patient. RN Karia was aware that Ms Douch was awaiting transfer to Cooma and had been reviewed daily by the Drug and Alcohol Team.
Ms Douch was complaining of pain and agreed to try a hot pack to ease her pain, as well as walking to try to alleviate her pain.
RN Karia looked after Mrs Douch on the 4 July 2016. On that day she was teary and reported pain. Mrs Douch asked to speak with RN Karia. RN Karia spent a period of approximately one hour speaking with her. RN Karia wrote in the hospital progress notes about that conversation however, she did not refer to the whole of the conversation.
RN Karia indicated that she was aware that Ms Douch had taken an overdose of poly pharmacy medications. However, it was her view that this was because of the pain she suffered. RN Karia said she was unaware that Ms Douch had taken an overdose for the purposes of attempting to suicide.
RN Karia indicated that she did not refer in her notes to all the conversation between herself and Ms Douch, because it was an oversight as she was on duty. RN Karia also admitted that she left out some important factors, such as being told that Ms Douch did not want to kill herself because of her grandson. Ultimately, RN Karia accepted that she had failed to put things which were important in her note on the file.
RN Karia stated that because she was the team leader, had a full load of patients and it was overnight, she had insufficient time to write everything down. In her view, she did not believe that what she was being told meant that Ms Douch wanted to end her life, she merely meant to end the pain.
RN Karia said that she had not had time to review all the notes but was aware that Ms Douch had been reviewed by the psychiatry team. RN Karia indicated that Ms Douch had been moved to room 2 because of some chest pain she had suffered. Mrs Douch asked if she could walk around the Ward to alleviate that pain. RN Karia gave her
permission to do so as long as it was with her husband. This was because she was concerned if she had chest pain, she needed someone to be with her.
On 5 July she saw Ms Douch and her husband walk towards the exit to the ward together. Later she saw Ms Douch walked past her during the hand over between the staff. Ms Douch was walking in the same direction she had seen her earlier walk with her husband. Ms Douch apologised to the staff because she thought she was distracting them when they were participating in the hand over. RN Karia did not see Ms Douch go through the exit door.
On 5 July 2016, enrolled nurse Shepherd was tasked to look after Ms Douch. Later that night, RN Karia was advised that Ms Douch and had a cardiac arrest and her resuscitation was unsuccessful.
RN Karia said that she had not seen the note written by Ms Douch and later obtained by the Police.
RN Karia agreed that her role was to understand the presenting complexities that Ms Douch had been admitted for. RN Karia agreed that she should have known the reason why Ms Douch had overdosed. RN Karia said she was not made aware of the potential for self-harm because she’d been deemed safe by the psychiatrists in any event.
RN Karia agreed that RNs rely heavily on the hand over because they do not have sufficient time to review all of the notes. Unfortunately, that means that if someone misses something in the hand over it would not necessarily be picked up by the oncoming staff.
RN Karia said that the patient load she had was 6.4 patients per RN on that evening as well as carrying the role of team leader.
RN Karia indicated that she had some training in identifying risks in patients, as Ward 7B does admit patients who overdose, although she stated that she is not trained as a mental health RN.
RN Karia stated that she had concerns in relation to Ms Douch as to her suicidal ideation or intent, given the conversation she had with her. RN Karia accepted that, in hindsight, her discussion of taking an overdose to relieve pain was an expression that she wanted to suicide.
RN Karia accepted that, hypothetically, it was critical to note any changes in information that contradicts the story such as ‘it was not suicide or I did not take them to kill myself just to relieve pain’ where a patient tells you ‘I did it to end things’, and agreed those matters must be noted. RN Karia agreed she did not mention, in her notes, the conversation she had with Ms Douch, particularly the taking of pills out of sight of her husband whilst he was watching television.
RN Karia agreed that was an expression of past suicidal intention. However, in her view Ms Douch clearly indicated that she took the overdose to try and end the pain. RN Karia agreed that in hindsight, she should have turned her mind to whether that was an intention to commit suicide because of the pain being too great or whether it was to stop the pain.
RN Karia stated that she told other staff some of the conversation which she had agreed to keep private because she wanted them to know the information so that she would be
looked after properly. The information was also relayed because she wanted the doctors to also know about the conversation.
RN Karia stated that there were some issues that arise as night shift team leader, one being she was not able to pass on the information to the treating team because they commenced their shift after she had finished hers. She also did not contact the clinical RN coordinator because she had other patients to look after and, in her view, this wasn’t urgent enough or Ms Douch was not physically unsafe.
In hindsight RN Karia believed she would not have done anything differently that night.
Dr Myint
Dr Myint was not Ms Douch’s primary general practitioner. However, he did treat her primarily for pain which was chronic. Usually she would be treated by Dr Pate and the pain management clinic.
Dr Myint treated her on 27 June 2016. He prescribed her Oxycodone and OxyContin.
Dr Myint saw her the next day in hospital, after she had taken an overdose, as he was the duty doctor. Dr Myint said that he stabilised her and gave her Naloxone which she responded to. Dr Myint asked the family to go and get the drugs that she had at home as well as the drugs she had taken. Dr Myint also said that the daughter had brought in a suicide note Ms Douch had left behind at home.
Dr Myint said that he contacted the ED at TCH and spoke with Dr McGivney who was the retrieval Doctor from TCH. Dr Myint thought that he may have told the retrieval team about the suicide note. Dr Myint said that the medical notes and the suicide note went with her to TCH.
In cross examination, Dr Myint said that he made an assessment about what drugs Ms Douch had left from those prescribed and noted that she was only due a renewal for Oxycodone and Endone. Dr Myint said that he generally trusted the patient and given it was a renewal of prescription he was not alarmed.
Dr Myint said that he did read the suicide note and advised that the hospital notes, together with the suicide note went with the medical notes to TCH. When Dr Myint was advised that the note did not go to TCH he was surprised because he thought it had.
Dr Myint said that he had told staff that the note was to go with her in the retrieval ambulance.
Evidence in Relation to Ken Alexander Lucas Comments by Brian Lucas, Ken’s brother Growing up Brian and Ken shared lots of fun times. They shared a passion for football and motorbike riding. They spent lots of time together when Ken was home. After finishing his apprenticeship Ken enjoyed travelling abroad and travelled overseas extensively. He travelled with friends, by himself, and with us as a family. Ken was a softie.
He did not cope well with illness. When his mother was unwell and dying he stayed away, only coming home after she had passed. When Brian had open heart surgery and was in ICU Ken, while with us in the waiting room and staying at the hotel, could not visit him in ICU.
He was okay once Brian was back in the world. When his father was dying he once again sought refuge offshore and stayed away, only coming home after his father passed. No-one held this against him, and this was Ken. He could not deal with this type of thing.
Ken worked offshore, and when onshore he lived on the family farm until it was sold in 2007 after Brian had open heart surgery. He brought a house in Yarram that's 15-minutes drive from the farm. Ken was a huge part of our family. He was particularly close to our daughter Amanda.
Prior to 2012, as I said previously, Ken was a huge part of our family. He and Brian were very close. They were best friends. He loved his family. His nieces and nephews were everything to him. He enjoyed family holidays with us. Christmas and Easter were always special. Ken loved being around the children, seeing their achievements. He also had lots of good friends who he spent time with and travelled with.
He was a popular member of our community. He had a heart of gold. Brian and our son Jason were with Ken when his life support was switched off, as was Ian and his family, who live in Canberra. There are many things we should have done differently in hindsight. We wish he had come home to Woodside. We are not saying that the outcome would have been any different, and hindsight is a wonderful thing.
Comments by Ian Lucas, Ken’s older brother I am Ken's older brother. The following is my recollection of events leading up to Ken's death.
Unfortunately, I'm not 100 per cent sure of all the dates and names as I lost my SMS message relating to the time following a phone reset. Ken came to my house in July 2016.
He said that he had done so because he needed to leave Melbourne. He said that he was fearful of people who he said his then de facto partner was associating with. He said that he had left her permanently.
After reflecting overnight I said to Ken the next I thought it likely that he was suffering from delusions again and that we should seek treatment for him. I asked if he had been taking any medication. He had been prescribed antipsychotic medication following his previous suicide attempt in 2012, and he said he hadn't. I arranged an appointment for Ken with a mental health trained GP in Watson a few days after he arrived. The GP prescribed Serepax and referred him to a clinical psychologist. She did not favour referring Ken to a psychiatrist.
Ken subsequently lived in my house uninterrupted, including for six weeks while I was overseas. On the evening of Friday, 4 November, we had a family dinner at my house. My daughter Gemma was worried about Ken's demeanour and spoke to him privately after the dinner. Ken told her that he had been considering suicide. Gemma phoned me from her
home afterwards and urged me to contact ACT Mental Health. I said I would do so the next day.
Ken was not in the house when we got up at 7.30 or so on Saturday, 5 November. His bedroom was uncharacteristically open. His car was gone and he was not answering his mobile phone. I was very worried by this in light of my conversation with Gemma the previous night. I called the ACT Mental Health Crisis Team who recommended calling the Police, which I did. As it happened Ken had been at Googong Dam out of mobile range. We eventually managed to reach him and asked for him to come home. He arrived home at 10 am or so.
The Police had already been and came back after he arrived. The ACT Mental Health Crisis Team arrived a bit later. On their recommendation we went to Canberra Hospital for assessment that Saturday, 5 November. The staff at Canberra Hospital recommended that Ken be admitted to the short stay facility as a voluntary patient. As I recall the message was that Ken should go into hospital as a voluntary patient, but if he didn't do so they would consider admitting him as an involuntary patient. Ken and I agreed that he should enter as a voluntary patient. I was supportive of this approach. Ken complied, although I could tell he wasn't enthusiastic.
During the time he was there we had a meeting with the hospital psychiatrist. He said that he would keep Ken in the short stay facility for a few days, then transfer him to the mental health ward. The understanding was that he would stay under observation for a short but indefinite time. In that meeting I asked if Ken would be able to come out with me during the day when he was in the ward, and the psychiatrist said yes he could come out for a few days under my supervision. The reason I asked was because I knew Ken would find incarceration in the ward difficult and I wanted to make it as easy as possible for him while also ensuring he was getting professional help.
Ken was transferred to the longer stay mental health ward around the middle of the week, 9 or 10 November. On the evening of Saturday, 12 November, he hanged himself in his room in the mental health ward. He died on 17 November after life support was withdrawn with the consent of me and our brother, Brian.
Constable Paul Reynolds
Constable Reynolds was the investigating officer in this matter. He received witness statements from Ms Hemming ACT Health in relation to AMHU staff.
Constable Reynolds is a trained investigator with many years’ experience in investigation. Constable Reynolds said he was hampered in the investigation of this matter because of the nature of the death being several days after the attempt at suicide. Constable Reynolds was not provided with the names of relevant witnesses.
The Directorate provided him with statements of those considered by the Directorate to be relevant witnesses. Constable Reynolds said he received those statements some 15 months after the event, as a result he was still not aware of whether there were any other relevant witnesses as he was not provided with any information in that regard.18
Other than the history he obtained from the family, he relied on the produced statements and what they contained. Constable Reynolds did not provide any questions to be considered by the witnesses.
Given the lack of time he had to review the statements, he was unhappy with the finished product as he did not have time to ask further questions in relation to the statements.19 Anish Modak
Dr Modak, in 2016, was a first-year psychiatric registrar who worked at the AMHU and MHSSU.
On 6 November 2016, Dr Modak first saw Mr Lucas in the MHSSU. Dr Modak reviewed notes in relation to Mr Lucas and spoke to Mr Lucas and his brother.
Dr Modak was aware that Mr Lucas had identified suicide ideation recently but denied it was present at the time. After reviewing Mr Lucas, Dr Modak was unsure of his diagnosis and questioned whether his diagnosis was psychosis and delusion or whether it was severe depression with associated psychosis and delusion.
Mr Lucas was agreeable to stay as an inpatient in the AMHU, without leave, and was placed on an ARC 2 score which placed him on hourly observations. Dr Modak said that if it was necessary to increase the level, he would have noted it down at the time.
The next time Dr Modak reviewed Mr Lucas was on 11 November 2016 with Dr Ahlin, at approximately 17:00 hours. An RN accompanied Mr Lucas to the consultation. Dr Modak opined that usually the RN looking after the patient would accompany them but that was not always the case.
At the consultation Mr Lucas denied being suicidal. Both Dr Modak and Dr Ahlin agreed to try new medications to treat Mr Lucas’s anxiety and stress and placed him on an antipsychotic.
Dr Modak and Dr Ahlin also agreed to change his ARC score to 2.5 which represents that half hourly observations are required. The RN who attended the review was in the room when that conversation took place and would have heard the conversation, 18 Transcript of proceedings dated 13 April 2018 (p 31).
19 Transcript of proceedings dated 13 April 2018 (p 32).
according to Dr Modak. Neither Dr Modak nor Dr Ahlin spoke directly to the RN in relation to changing the ARC score to 2.5.
Both Dr Modak and Dr Ahlin agreed that Mr Lucas could have leave arrangements but only if he was in the company of his brother, Ian Lucas.
Following the consultation, Dr Modak changed the medication chart to reflect the new medications prescribed. It was noted that Mr Lucas was not given his dose of Aripiprazole as prescribed. However, that drug would usually take between one and two weeks to have any effect, so it was unlikely that the missing of that dose had an effect upon Mr Lucas.
Dr Modak also completed the ARC reassessment and determined that Mr Lucas was at medium risk of suicide. Dr Modak circled ARC score at 2.5. Dr Modak stated that he then gave it to the RN who co-signed the document.20 Dr Modak stated that he told the RN to pass this change on.
Dr Modak stated that the RN who co-signed the document was not the same RN who accompanied Mr Lucas to the interview. Dr Modak said he did not know whether the RN who co-signed the document was the RN looking after Mr Lucas. Dr Modak said it was his belief that the established practice was that the RN who signed the document would also tell the other nursing staff of the change.
Dr Modak said the practice has now changed since Mr Lucas’s death and that the ARC forms are kept together, and the changes are written on the hand over sheets.
Dr Modak said that it was his understanding that RNs were appraised of changes through reading the clinical notes and at the verbal handover.
Sarah Eldridge
RN Eldridge graduated in nursing in 2014 and completed her mental health training in
She started working at the AMHU in August 2016. RN Eldridge was the RN who co-signed the change in the ARC observation for Mr Lucas on 10 November 2016.
RN Eldridge was, as per procedure, required to advise the team leader and the RN allocated to look after Mr Lucas.
On the 10th and 11th of November 2016 she worked an afternoon shift and a double shift of night shift. It was during the shift on 10 November that she co-signed the ARC observation change with Dr Modak.
RN Eldridge stated that she has no recall of the actual event, but it was her usual practice to advise the team leader of the change as well as the RN looking after the patient. During these days Mr Lucas was not her patient.
It was suggested to RN Eldridge that she had not told the team leader, nor had she told the RN looking after Mr Lucas. It was suggested that assertion was supported because on the documentation in the MHAGIC notes after the ARC had been changed to 2.5 by Dr Modak, she had written ARC as 2. RN Eldridge had also completed the 10:00 hours to 14:00 hours observations, including Mr Lucas, and had done them hourly not half hourly as required.
20 Transcript of proceedings dated 13 April 2018 (p 53).
Further at 23:00 and 24:00 hours she was still conducting hourly observations rather than the half hourly observations required, despite knowing that she had signed the change in the ARC as being 2.5.
RN Eldridge accepted that she may have not advised the team leader or the RN looking after Mr Lucas. RN Eldridge accepted that she may not have followed the usual practice.
It was suggested to RN Eldridge that she had done something similar on 16 November and was shown a ‘Riskman’ outlining the failure to again advise of a change in ARC.
RN Eldridge said she was not aware of this and had never been shown that document.
I note that there was at the time no requirement to advise in the notes or anywhere else that the person co-signing the change in ARC had advised the team leader and the patient’s RN.
RN Eldridge indicated that her statement was drafted by ACT Government Solicitors and she had provided the statement only recently when she was interviewed by the Government Solicitor.
RN Eldridge was never offered the opportunity to speak to Police regarding this matter and said that she would have, had she been offered. I note she was asked whether she was happy for the Government Solicitor to take her statement and she said she was.
Martin Ngor
RN Ngor trained as a registered RN and as at the 11th and 12th of November 2016 was undertaking his mental health RN training.
I note that RN Ngor made a significant number of changes to his statement in the witness box. RN Ngor said he completed his statement in 2016 some two weeks after the event but did not sign it at the time. I note at the time he did not have access to any of the medical records. Many of the times he put into his statements were incorrect and had to be changed when he had the benefit of those documents.
RN Ngor was on his rounds on the night shift the night Mr Lucas died. RN Ngor said that he as part of his observations checks the facility which includes the patient’s rooms, he uses a bed list and then when he completes his rounds, he signs the ARC sheets which are left in the RNs station.
RN Ngor said he went to room 40 and found Mr Lucas was not in his room. He said he saw a bedsheet tied to the handle of a door, which I note was an anti-ligature type handle, it was then slung over the door and it was pulled tight.
RN Nkomo was with him at the time and called a code black from her personal security call apparatus. Once it was realised that Mr Lucas was hanging from the other side of the door a code blue was called. Neither, RN Nkomo, nor RN Ngor were able to open the door. Eventually RN Ngor was able to slip the sheet from the anti-ligature handle and ultimately got into the room.
RN Ngor and a wardsman conducted CPR until the MET arrived. RN Ngor said that there had been a white chair in the bathroom when he opened the door. That chair was similar to a chair in the dining room area. RN Ngor said it was not unusual for patients to have chairs in the room like the chair found in the Mr Lucas’s ensuite.
RN Ngor said that the CRA and CRA reassessment forms were not documents which he would see on commencement of his night shift. They are kept at the RNs’ station.
RN Ngor said that it is usual for RNs to check the MHAGIC notes but not the RNs who do the observations rounds.
RN Ngor said that he was not aware that there had been other hanging deaths in AMHU. Neither was he aware that the hinged door in the bathroom of the rooms could be opened so that access can be gained to the bathroom. RN Ngor now knows that that is possible but only those in senior positions have keys for that access.
RN Ngor said he gave his statement in 2016 and he was never offered the opportunity to speak to Police or the coroner’s investigator, but he would have done so had it been offered.
Michael Golding
Mr Golding is a trained general and mental health Registered Nurse. He commenced work in the AMHU in June 2016. In relation to this matter he signed his statement in February 2018.
In September 2016 he was a RN educator. Part of his work was to identify skills deficits and correct them by training. On 12 November 2016 he commenced work at 09:00 hours and completed a double shift.
He identified the document At Risk Categories (ARC) as a form he recognised. Mr Golding said that a team leader prepares a handover sheet for each shift change. Client Risk Assessment (CRA) and Client Risk Reassessment (CRAR) are risk assessments for each client but are referred to by the staff as leave forms but they are not actually leave forms.
Mr Golding said that the team leader prepares the handover sheet which includes the ARC which is recorded in the handover sheet. When ARC is changed the RN co-signing the form with the psychiatrist must tell the team leader orally so that they can included the change in the handover.
Since Mr Lucas’s death, changes have been made in both the CRA and the ARC. They are kept together in one folder. Mr Golding suggested that he is of the view only one form should be used, and everyone knows exactly what the CRA is and therefore the ARC level.
Mr Golding said that on the form he signed on the 12th of November, he did the observations on an hourly basis because he assumed that the ARC level was 2.
In relation to the co-signing of the change to an ARC level, he would immediately tell the team leader of the change. He said there was no practice or process of writing something to the effect that there was a change to the ARC level in the notes.
In relation to the white plastic chair, which was found in Mr Lucas’s room, Mr Golding said that the chair should not have been in his room and if he had seen it, he would have removed it.
Mr Golding indicated that he randomised his checks so as not to be consistently on time. Mr Golding said that he checked Mr Lucas’s blood pressure and noted that it was slightly higher than normal. Mr Golding stated he conducted a mental state exam upon Mr Lucas as well.
He described Mr Lucas as thought blocking, having latency of speech, blunt affect but he denied thoughts of self-harm. Mr Golding indicated that he had never experienced a patient who had denied thoughts of self-harm then go on to commit suicide.
Mr Golding stated that when the RNs access the MHAGIC notes they would not see the note written previously by someone else who might record information. He indicated that that was why the RNs who entered the information following Dr Modak’s entry would not see his entry, unless they specifically clicked on that entry.
Mr Golding stated that on 12 November, Mr Lucas’s brother and a friend visited him.
Mr Golding stated that he now works for the Royal Darwin Hospital and in that facility, doors cannot be locked from the inside and in fact they are locked open. Further they do not have door handles but recessed fittings.
Mr Golding stated that he is empowered to increase the ARC level if he thinks that it is necessary.
In terms of training Mr Golding’s said that he did not find any barriers from his superiors to training at the AMHU.
Mr Golding stated that when he checks a patient’s room he would advise a patient of his intention casually so as not to alarm them and he would reflect on the patient’s demeanour and if aggressive he would take precautionary measures and search in a limited way but eventually he would get security or another RN to assist him to complete a more fulsome search.
Mr Golding stated that he did search Mr Lucas’s room and was surprised to learn that the Police had found that there were two bottles of brandy hidden under his mattress.
Mr Golding stated that he did not observe any signs of intoxication in relation to Mr Lucas.
Mr Golding stated that he was aware of how the ‘piano’ hinged door worked and had been shown that at his orientation.
It was Mr Golding’s view that the level and mix of staff would benefit from more experienced mental health RNs. However, at the time there was a mix of recently qualified RNs some with no mental health training and agency staff with no mental health training and limited experience in the mental health facility. There was a staff shortage which resulted in him and other staff having to often do double shifts.
In terms of recommendations, Mr Golding was of the view that the doors need to be reviewed, there should be better training and orientation for staff as well. Mr Golding also recommended that there be full-time educators permanently in the Unit, a better staffing mix with rostering which also supported training team leaders and staff.
Busisiwe Nkomo
Ms Nkomo has been a registered RN since 1984. She completed her mental health diploma in 2010 after training in South Africa. She moved to the Australian Capital Territory in 2003 and worked in the mental health ward from 2008.
RN Nkomo was often team leader on the night shift. Her duties were to allocate work to staff. There was usually about eight RNs for the full unit including the team leader.
RN Nkomo said that the afternoon shift team leader would give a handover to the
incoming night shift team leader. This includes a handover sheet which is a bed list as well as a verbal handover.
RN Nkomo said she would expect any changes to the ARC to be handed over to her at the change of shift by the team leader. RN Nkomo said that if a person was doing a double shift they don’t necessarily come to the handover because other jobs need to be done in that time. It was her view that at shift change the incoming shift leader relies on the verbal hand over and the bed list from the outgoing shift leader.
RN Nkomo said “after one admission, the patient comes in with a clinical risk assessment. There is one that we carry until the patient is reviewed and the doctor decides to renew the CRA, to do another reassessment, so when a reassessment is done, a new form is completed and this form then gets put with the other notes in the green folder, and this is now the running form that is put with the other CRA’s together in a white folder.”21
RN Nkomo said that in terms of a doctor changing the ARC score, her expectation was that the RN looking after the patient should co-sign the document. If that was not possible the RN who co-signed the document should inform the shift leader in charge.
The bottom line is that the person who co-signed the document has an obligation to advise the team leader and or the RN who is responsible for that patient. RN Nkomo said that there is no documentary trail to support that practice, it is all verbal. However, the RN looking after the patient does write notes about each patient in the clinical notes which does not necessarily need to be on MHAGIC. RN Nkomo agreed that the process had broken down in relation to Mr Lucas.
RN Nkomo said that at the beginning of her shift, she always took the first two observation rounds and conducted an environmental check as well. RN Nkomo said that she would also check the CRA forms but that was not the standard practice.
RN Nkomo said that her first check commenced at 21:30 hours, this was essentially the 22:00 hours check. If a patient had been on a 2.5 ARC which required 30-minute observations that would be done at 22:00 hours and would the marked on the form as such.
RN Nkomo said it was the team leader’s responsibility to lock all the doors in the Social Spine including the toilets.
RN Nkomo said that if a patient had been placed on a 2.5 ARC, she would allocate an RN to do all of the 2.5 observations on the night shift.
RN Nkomo said that the observation rounds took approximately 15 minutes to complete however the environmental checks took longer. RN Nkomo said that she would stagger the observation rounds. She described how she conducted her rounds and said that she shines a torch into the patient’s room but does not go into the room if the patients are sleeping because it disturbs them.
RN Nkomo said that if she saw something that should not be in a patient’s room, such as the white chairs which belong in the dining room, she would remove them. RN Nkomo said that the environmental checks are done at the beginning of each shift.
21 Transcript of proceedings (p 51.40).
During the shift, RN Nkomo said she would print the patient notes from the MHAGIC system utilising the to and from dates so that a hard copy could be available for those who did not have access to the MHAGIC notes.
Mr Lucas was admitted on a night shift on 10 November from the Short Stay Unit. RN Nkomo considered Mr Lucas to be at high risk because of his thoughts of suicide the day prior to his admission and the fact that he was not eating or drinking.
RN Nkomo wanted Mr Lucas to be closer to the RNs station but there were no closer rooms available at that time of the night. On admission she checked his belongings and noted there was no alcohol present as it is not allowed and if there had been anything which was contraband, she would have kept them in a locker for him.
RN Nkomo asked Mr Lucas the next morning if he had any thoughts of suicide or selfharm which he denied.
On 12 and 13 November, RN Nkomo said that the Unit was full to capacity with 40 patients on the ward during her night shift. On those nights she was the team leader.
The Unit had nine staff that night.
RN Nkomo said that during her shift, she shone her torch into his room but did not see him in his bed. On further inspection she saw that the bedroom door was jammed shut and there was a sheet fixed to the outside door handle of the bathroom. She said that she called a code black and yelled out for help from other staff. RN Nkomo said that she also asked for the MET trolley to be brought to the room.
RN Nkomo said that they had difficulty opening the door and, in her panic, she forgot that she had the key to the side panel piano hinged door. Eventually it was opened and they were able to get into the door and get the sheet off the handle. This took no longer than 2 to 3 minutes in her estimation.
RN Nkomo said that she saw a chair from the dining room in the bathroom and that it should not have been there. RN Nkomo said that she assisted with the resuscitation until the MET arrived and ultimately Mr Lucas was transferred to the ICU.
In relation to the original ARC form for the 11th and 12th of November, she had kept a copy of it because she was not sure whether Mr Lucas had access to leave the day before. She left the copy of it in her locker at work and then went on holidays.
She was made aware that the original had gone missing and fortunately she was able to provide a copy of it to management. RN Nkomo said that when she made the copy, she placed the original back on the file and that file went with Mr Lucas to the intensive care. RN Nkomo is now aware that his ARC level had been changed but she was not made aware of it at the time.
RN Nkomo said that there have been changes since Mr Lucas’s death. The CRA and ARC are now kept together and the RN who looks after the patient has them. Since that time and with the implementation of the new practice there has been no failures to change the ARC score.
The ARC forms are carried with the RN who is looking after the patient and is ticked off on completion. On night shift there is an exception where all of the CRA’s are checked and placed into a bundle at the RNs station and the ARC’s are inserted into the bed list.
There has also been a change in relation to the observations. RNs are now divided into two groups and the observations get done faster and earlier for the patients. Chairs must also be removed from patient’s rooms.
RN Nkomo said that the keys to open the piano hinges are still only carried by a few RNs.
RN Nkomo agreed that the handles used in the bedroom, and I note in all the other doors in the units, were still being used in 2017, and I note clearly still being used in
RN Nkomo indicated that the Social Spine doors have changed, and they are now recessed.
RN Nkomo said that she would have been happy to speak to Police as she had nothing to hide however, she would have checked with her supervisors first.
RN Nkomo was asked her opinion as to what she would have changed, and she said she would not have admitted him to the Unit and into bed 40 she would have kept him in short stay. RN Nkomo said that she would have pushed for the ward not to go over the numbers of patients appropriate to the Unit and would like more experienced staff to look after patients.
In terms of recommendations, she said the number one recommendation she would insist upon was the removal of those handles which I agree with. RN Nkomo would also remove the doors to the bathrooms.
better staff to patient ratio,
patient numbers should not exceed the proper number of patients for the Unit,
there needs to be more training of staff in mental health nursing,
education of new staff particularly from the staff pool. These staff should be trained in mental health if they are working in the Unit.
Dr Ahlin
He is a consultant psychiatrist with international experience in psychiatry.
He reviewed Mr Lucas with Dr Modak in November 2016 and recalls he had some difficulty with communication with Mr Lucas and noted that his speech was slow, and his answers were brief. He also noted that an RN was present for the whole interview.
Dr Ahlin stated that he questioned Mr Lucas in relation to his symptoms and according to the DSM5, if a patient has five out of the nine accepted criteria they are diagnosed with depression. Mr Lucas met that criteria and was diagnosed with depression. It was Dr Ahlin’s view that he was severely depressed. Dr Ahlin was not able to determine whether he suffered from psychosis.
Dr Ahlin stated that Mr Lucas denied thoughts of suicide or self-harm but given that he was recently admitted to the ward and had significant risk factors, Dr Ahlin decided to increase his ARC score to 2.5 which meant that he should be monitored every 30 minutes.
Dr Ahlin recalls instructing Dr Modak to increase the ARC and at the time of that increase he observed an RN present in the room. It was his understanding that Dr Modak would clarify this position with the RN and they would co-sign the document and that the RN would then inform the members of the nursing staff.
Dr Ahlin was asked questions in relation to any recommendations for safety in the Unit and the first item he referred to was the doors, including the bedroom and bathroom doors. It was his view they were not safe if they can be used as ligature points. He added that no ligature points mean people can’t hang themselves. Dr Ahlin stated that the wards he had worked in previously had recessed handles so that the handle did not present as a ligature point.
Dr Ahlin also suggested that the design of the Unit was susceptible to risk because of the different corridors and the size of the Unit. Dr Ahlin stated that the units where he had worked overseas, had small wards such as 12 to 16 patients and said the ward he was working on presently had 10 patients.
Dr Ahlin said that he had never worked in a unit where he could not allocate an RN to do 15- or 30-minute observations. He also said that the continuity of RNs with patients is very important and it was his experience that didn’t happen in the AMHU. Dr Ahlin observed that there were many locum RNs and that is not best practice.
Dr Ahlin agreed that having a patient’s prior medical history is very helpful in reviewing the patient. Dr Ahlin also stated that he did consider one-on-one nursing for Mr Lucas.
Dr Ahlin also said that he knew that pressure pads on doors were frequently used in psychiatric wards.
Andrea Nissen
Ms Nissen became a RN in 2014. During November 2016 she had not worked many night shifts but had a basic idea of the differences between the day and night shift including the allocation of staff. RN Nissen indicated that patients are allocated to staff members in the day shift but not at night.
RN Nissen said that the outgoing team leader would sit with all the oncoming staff. She would provide a fire list and then do a handover to all staff. The high dependency staff would then leave, and the rest of the staff would have handover in relation to the low dependency unit. The team leader coming on would allocate workload and tasks.
It was a requirement for the team leader of the outgoing shift to update all lists in relation to each patient. They did this by updating the list they had been given, together with any changes taken at the handover from the RNs on that shift. The team leader would then update the list, print and disseminate to staff who required them. The information held on the computers was updated when things changed. RN Nissen said that she did not access the MHAGIC notes for the handover.
RN Nissen said that team leaders did not access the MHAGIC notes for the handover.
If an RN was completing a double shift, they did not need to attend the handover of the shift change but would hold an oral handover with the team leader who would then pass on the information to the oncoming team.
RN Nissen said that it was during the day shift she would do an environmental round of the units but would only do a surface check as they are not permitted to look under mattresses unless they see something which would give them grounds to look.
RN Nissen said it was not uncommon, in 2016, for a chair which came from the dining space to be in a room and she would not ordinarily remove it.
In relation to the ARC documents, RN Nissen confirmed that in 2016 these were kept in a folder in the RNs station. The updated CRA was only used if there had been a change to the ARC level. RN Nissen said the updated form would supersede the previous form and the previous form would go into the file for night shift to file in the patient’s green folders.
The protocol in relation to reassessments made to the CRA was that it was preferable for the patient’s RN to attend the reassessment. If that was not possible the RN who attended and co-signed the document was expected to notify both the RN looking after the patient and the team leader.
If there was an increase in the ARC level, it required the team leader to update the bed list and make changes such as bringing the patient closer to the nursing station. This can be done by moving several other patients around so that the person with the increased ARC score can be moved closer to the nursing station.
RN Nissen said that she was meticulous with her hand over sheets and documents.
She did not look at the MHAGIC notes during shift unless something happened. That was because each RN knows they need to write up the notes on every shift. RN Nissen said she would access the system to check on whether changes had occurred and had not been documented. She gave examples of such things as leave entitlements or where patients had refused to take medications. It was in those situations that she would access the MHAGIC notes.
RN Nissen agreed that there was a significant reliance on verbal communication between the RNs and the team leaders. RN Nissen agreed that if something had been forgotten no one would know unless they looked at the notes.22
RN Nissen stated that she does not believe she was told about the change in the ARC score in relation to Mr Lucas. RN Nissen stated that she did not recall it happening and ordinarily she would not know that a review had been conducted.
RN Nissen said she was not aware of any medication change because that would be changed on the medication chart and generally that was not something that she would be made aware of. RN Nissen stated she did not see the recommendations made by the doctor in relation to the ARC level because she does not look at the notes.
RN Nissen stated she was certain that she was not told of this change because other things would have needed to be done such as moving patients closer to the nursing station, cleaning rooms and the like. RN Nissen stated that the only way she would have known about the change in the score was if she had been told by the RN who was present when the reassessment was done.
RN Nissen stated she did a double shift that day consisting of the morning and afternoon shift on 12 November 2016. RN Nissen stated she recalls doing an environmental check on Mr Lucas’s room and noted that it was tidy which was unusual for the ward and there was nothing out of the ordinary that she observed.
22 Transcript of proceedings dated 4 May 2018 (p 55.32).
RN Nissen reported that following the death of Mr Lucas, on 16 November 2016, Sarah Eldridge asked her whether she could backdate the ARC sheet because the patients ARC score had been changed. RN Nissen told her that it was not proper to do so because it was a legal document. RN Nissen then logged an incident and advised her immediate superior of the matter.
RN Nissen stated that Sarah Eldridge had forgotten to tell anyone about the change in the score and did not record the change either. The change in that patients ARC score was done at 10:30 hours and it was not until 20:30 hours that RN Eldridge asked whether she could change the score entries. At that time, RN Nissen was not aware that it was RN Eldridge who had failed to tell anyone about the change in the ARC level for Mr Lucas.
RN Nissen agreed that there was no documentary evidence that the change was brought to her attention, however, was adamant that if she had been told she would have taken the steps to change Mr Lucas’s bedroom as she had already indicated was the practice.
RN Nissen recommended that in future the team leader should also co-signed the CRA to indicate that they have been advised of the change.
RN Nissen stated that the expectation is that the RN who attended the revision should have told the allocated RN for that patient, as well as the team leader. RN Nissen said that if she had been the patient’s RN, she would have looked at the note from Dr Modak in relation to the review, as that was her personal practice.
RN Nissen stated that when she commenced in the Mental Health Unit, she did not have any specific training for handover other than a couple of Buddy shifts. Although she indicated that it was not too different from that which she had experienced in her years of nursing.
RN Nissen accepted that the nursing staff relied on the input from the patient’s RN at the handover and there were no physical notes, only an oral handover.
RN Nissen was asked some questions in relation to whether she would have accepted the Police speaking to her in relation to Mr Lucas’s death. RN Nissen stated that she had a vague recollection that the ACT Health told her that they would assist her in any investigative process. RN Nissen gave evidence that “if we were to be asked to participate in any line of questioning, that ACT Health be involved in the process”23
RN Nissen stated that she would not have changed her practice at the time. However, she now checks the CRA folder when she comes on shift. That is now the practice and she still checks the folders herself.
In terms of recommendations to the Coroner, RN Nissen opined there needs to be better training to up skill the RNs who work in the units.
RN Nissen stated that if she had been the contact RN that is the patient’s RN she would go back and check the MHAGIC notes of the Doctor who reviewed her patients if she had not attended the review.
23 Transcript dated 4 May 2018 (p 75.15).
Saria Roy
RN Roy completed her registered RN training in India and held a Masters of Mental Health Nursing.
RN Roy was working the afternoon shift on 11 November 2016 and did a double shift into 12 November 2016. It was only her third week working on the AMHU.
RN Roy indicated that the patient load on the unit was usually between five and six patients per RN. The usual practice was that the allocated RN on the incoming shift would have a non-formal chat with the outgoing RN who was looking after the same patients. The outgoing RN also introduced the patient to the incoming RN.
RN Roy indicated that she would then, after commencing her shift, check the CRA forms at least once per shift and that was her usual practice. RN Roy also stated that she would speak to the afternoon shift team leader at the end of each shift to update her about her patients.
On 11 November, RN Nissen was the team leader. RN Roy was allocated to Mr Lucas on that day. In relation to leave, RN Roy stated that it was not necessarily the case that the patient’s RN would be told the patient had returned from leave although she said that has now changed and it is most likely that the patient’s RN would be advised. The usual practice was that the person who collected the patient from leave would inspect any bags and if there was any contraband that would be kept in a locker and identified as belonging to the patient.
On 11 November, RN Roy cannot recall whether she met Mr Lucas on his return, but she said she would definitely have checked his bags and if she had observed any alcohol she would have told the team leader and would have confiscated the bottles and recorded it upon confiscation. There is no record of any confiscation of any contraband owned by Mr Lucas.
RN Roy stated that she completed the observation rounds pursuant to the ARC at each hour from 15:00 hours to 21:00 hours. She recorded those on the observation sheet.
RN Roy said that she escorted Mr Lucas to an assessment review on the evening of 11 November 2016. After the review when Mr Lucas had left, she discussed his case with the doctors. At the time she did not know much about Mr Lucas as she had only just met him. RN Roy recalls that there was a change to the medication but does not recall hearing any change to the ARC.
RN Roy stated that may have happened, but she did not hear the conversation and when she completed her notes, she did not change the ARC score and it remained at
RN Roy stated that she had has a practice of looking at the previous nursing notes to get a background in relation to the patient she is looking after if it is the first time she has looked after them. RN Roy did not recall Mr Lucas’s ARC score being increased from 2 to 2.5. At no time did she see the reassessed CRA form with the ARC changed to 2.5.
RN Roy indicated that there is an expectation that the RN who is looking after the patient would co-sign the CRA reassessment form but that is not always the case. There is
also an expectation that the RN who is co-signing the form would tell the RN looking after the patient and the team leader.
RN Roy stated that RN Eldridge did not tell her that there had been a change to the ARC score. RN Roy stated that RNs at the handover tell the team leader about their patients and any changes of note, such as whether they had been reviewed by psychiatrists. RN Roy did tell the team leader that Mr Lucas had been reviewed. RN Roy understood that it was incumbent upon the person who was at the review and who was aware of the change in ARC to tell the team leader.
On that day RN Roy did a double shift, which was an afternoon shift and a night shift from the 11th to 12 November.
RN Roy agreed that a change in the ARC score to 2.5 was significant and she said that if she was aware of the change, she would have told the team leader and also would have written it in her notes. RN Roy also stated that she would again tell the team leader at the handover as well. RN Roy denied that RN Eldridge told her of the change to the ARC score.
RN Roy stated that her practice was that if she co-signed a CRA form for another RN she would tell that RN and then get that RN to co-sign the document as well. That appears to me to be sensible and good practice.
RN Roy stated that she would have been happy to speak to Police if she had been asked to do so.
Phase 2
I heard evidence from the following witnesses in relation to practice and procedure at TCH: Helen Braun
Ms Braun was the acting Operations Director of the Adult Acute Mental Health Services.
Her qualifications are a registered mental health nurse and a BA Nursing Studies, Mental Health. Ms Braun had no direct involvement with the care of Ms Fisher, Ms Douch, Mr Lucas or Mr Bearham.
Prior to December 2017, there were 17 individual policies and operational procedures applicable to the staff of the AHMU. In 2017, those policies and procedures were collated into one operational procedure.
This document is subject to updates as required. The document is kept in electronic form and also hard copy, located in the High Dependency Unit (HDU) and Low Dependency Unit (LDU). There are reminders on how to access the electronic copy.
Notification of updates are sent to all staff.
An update to the document was undertaken in August 2018, which included changes to the clinical risk assessment and observations for patients. It appears that these changes were completed after the findings from the Australian Commission on Safety and Quality in Healthcare Standards accreditation process.
The review of the accreditation survey revealed that there were extreme and significant risks identified for mental health inpatient services. There had been ‘significant concerns expressed by the survey team regarding a number of issues in mental health and the number of suicides in the health service over the past three years which had not had a robust review nor strategies implemented to mitigate the risk’.24
Ms Braun read out the comments made by the review team which stated that: “despite all the recent work to address the National Safety and Quality Health Service Standards in general, that the organisation has undertaken, there is significant concerns by the surveyors around five suicides over the past three years within inpatient units of the health service. Four deaths in mental health and one death in a general medical ward. There was no immediate commissioning of any external review for all four deaths, nor was there a robust RCA undertaken in three of the cases. There was some form of general feedback with some suggestions, but this failed to make any significant impact.
There was a report undertaken by an external architect on ligature points in January 2017, and a Gantt chart has only been developed to commence in February or March 2018, over 12 months post the review. There appears to have been no regular ligature point audit undertaken, nor was there any action plan done to implement strategies to prevent further cases”.25
24 Annexure B to the Statement of Ms Braun dated 24 August 2018.
25 Transcript of proceedings dated 4 September 2018 (p 125. 20).
Ms Braun identified that at the time of accreditation, the bathroom doors had already been or were in the process of being removed. Ms Braun said that had the first remediation plan been acceptable the doors would have already been removed by the time of accreditation.26
The review was undertaken by the North-Western Mental Health, which is part of Melbourne Health. That review team provided a report making recommendations in relation to the workforce, governance, quality managers, occupational violence, external benchmarking and ligature safety. Following the recommendations, an independent mental health advisory body was convened to oversee those recommendations.
Ms Braun stated that the recommendations contained in the review report are being actioned by Mental Health Justice Health Alcohol and Drug Service and overseen by the mental health advisory body.
Ms Braun indicated that the recommendations made by the review panel are being actioned.
In relation to workforce, the action undertaken so far is to recruit RNs with specialist training and for that purpose a project officer is being recruited to engage in that strategy.
In relation to governance, Ms Braun indicated that the organisation, as of 2018, has split into two ministries and mental health will sit within the health services.
In relation to the review’s recommendation for a root cause analysis, The Canberra Hospital Health Service does have an investigative process, which would complete their investigation within 100 days of an incident. The Executive Director of Quality and Safety is seeking consideration for that change to be less than 100 days in line with the Victorian health service recommendations.
In relation to governance, ACT Health has devised a partnership model for each program area, with each unit having a lead doctor and a lead RN and an overarching clinical director. The recommendation from North-Western Mental Health was to have each unit within a program area to also have a lead doctor and lead RN or allied clinician with an overarching director. ACT mental health are looking to engage with that strategy.
Ms Braun explained how that would work. There would be the overarching clinical director, a lead doctor as clinical director, and within the three units a lead doctor and RN in each of those units.
In relation to quality improvements, recommendations have been actioned and there has been a commitment that the mental health division would have a dedicated quality officer.
In relation to external benchmarking, that is being explored using either New South Wales or Victorian Departments of Health.
26 Transcript of proceedings (p 125).
In relation to ligature safety, some of the recommendations have been implemented, including appropriate soap dispensers, and door pressure sensors on all bedroom doors.
I noted that on the two occasions I conducted a view at the AMHU the supposedly non ligature door handles were still in place. Clearly this design has potential to be used as an anchor point for a ligature.
The report dated January 2017, into door hardware and design in the mental health inpatient units advised that there were no current pressure sensors fitted and the rooms in the units were of significant risk of ligature points. Pressure sensors would significantly mitigate that risk. It also notes that the system of sensors has been implemented at the Dhulwa Mental Health Unit.
The report also indicated that the door handles throughout the unit had an increased risk because of its design. The authors recommended the Kaba 2900 series to mitigate the risk.
I note that the Kaba 2900 series has several types of handle, including ones that are recessed, which in my view are appropriate. The actual recommended handle was not provided in evidence before me.
Ms Braun accepted that the door handle used by Mr Lucas was of that type signified as being of significant clinical risk. I note that this report was prepared in January 2017. I note that the walk-through in preparation of the report was conducted in December 2016.
Ms Braun stated that a program for all the bathroom doors to be removed commenced in December 2017 and was finalised in May 2018. The door handle to be affixed are flat to the touch with a twist action to open the door, there is no ligature or anchor point.
The second part of the review was on operational systems review to reduce ligature risks. Four recommendations were made in the report. Ms Braun advised that the recommendations have been implemented and are now procedure, as set out in a document entitled ‘Canberra Hospital and Health Services Operational Procedure Ligature Risk Management for Mental Health, Justice Health and Alcohol and Drug Services Inpatient Mental Health Units’.
That document outlines the protocols in respect to ligature risk management, environmental safety checks, risk assessment and risk reduction action plans and the like. In respect to ligatures, there are procedures in relation to ligature cutters being utilised.
Ms Braun also indicated that there have been changes to the Clinical Risk Assessment Process utilising the Victorian version of that document. The document includes not only risk of self-harm, harm to others but also areas of vulnerability.
In terms of a comprehensive mental health assessment, Ms Braun stated that one looks into previous traumas, previous experiences, previous risks as well as dynamic factors, which are the psychosocial stressors affecting the person in the present.27
In terms of changes to the clinical risk assessment, changes have been implemented to include the psychiatric registrar or consultant signing the form. The RN looking after 27 Transcript of proceedings dated 3 September 2018 (p 35.17).
the patient also signs that they have received the information and the form. The RN in charge of the shift also cites and signs the form to ensure information is included in the clinical hand over.
Changes have also been made to place importance on therapeutic engagement rather than just observations. I noted to Ms Braun that it was common sense that such engagement was part of what informs observations. Ms Braun indicated that policies to date hadn’t explicitly noted that. I find it incredible that it has not been part of any practice or procedure
Changes have also been made to the location of the ARC forms are so that they are easily identifiable and readily available.
These changes have been made since the death of Mr Lucas and it was conceded that they were made because it was recognised that there had been a miscommunication and a failure in relation to the increase in the ARC score.
Protocol and procedure in respect to how and when observations are conducted has also changed, with intermittent and various times utilised to avoid patients becoming familiar with the routine. Actual times of observations are also to be recorded rather than pre-recording of that time. Staff have been utilising that process successfully.
Handover is now split up so that the RNs looking after a particular cohort of patients would hand over to the oncoming RN looking after that cohort, thereby leaving more time for the other RNs to conduct patient observations. There is also a hand over between the two team leaders both incoming and outgoing.
There is a new policy in relation to searching patient’s property which is hospital wide and also a specific one for Mental Health.
The procedure and policy take into account a person’s rights, responsibilities and dignity, to be respectful when advising them of the process and policy. When it has been explained, a RN will ask to search the belongings. If the patients refuse there are limitations, given they are voluntary patients. It then becomes a clinical risk assessment to determine whether the person is at a risk sufficient for consideration of removal of items which could be used to ligatures.
There have been significant changes in respect of the Mental Health Assessment Unit, which is now a short stay psychiatric unit, where a person is not just there for assessment waiting for a bed in the AHMU, it is an admission unit. There are mental health clinicians working in the Emergency Department 24 hours per day and they undertake mental health assessments. After assessment, a decision is made as to whether they go into the Short Stay Unit or the AHMU.
The Mental Health Short Stay Unit (MHSSU) is a unit containing six beds and prefers only patients with an ARC of 2. The MHSSU has a 48-hour admission turnaround as standard.
Ms Braun indicated that after Mr Lucas’s death she debriefed the staff who were quite distressed by his death. Ms Braun also encouraged all the persons involved to make a file note whilst things were still fresh in their mind. This is an excellent practice and is to be encouraged.
In December 2004, Ms Braun was working at the PSU (the predecessor to AHMU) as a level one RN. She was aware that Chief Coroner Cahill handed down findings into
the death of five persons who had died either whilst receiving treatment, or immediately after having received treatment by ACT Health and Mental Health Services.
Ms Braun could not recall whether any changes were seen on the PSU at that time and could not recall whether she received any informational briefing at that time either.
Ms Braun returned to ACT Health in October 2015 and had a nonclinical managerial role. That role involved policy work, planning, particularly in commissioning the new MHSSU. As well as training staff who were transitioning to that unit.
Ms Braun was aware that Mr Bearham and Ms Fisher had died at that time and was aware of the Clinical Review Committee findings in respect of those deaths. Those findings were handed down in August 2015.
Ms Braun clarified that she was not working at TCH at the time Mr Bearham committed suicide and was not sure who the team leader at the time was.
Several Clinical Review Committee recommendations were made, specifically in the areas of registrar coverage over weekends and public holidays, particularly in the MHSSU. That involved staff education and consideration of resources. The recommendation in relation to education and prompting of staff to review suicide vulnerability and assessment procedure revision occurred in 2015 and was closed in 2016.
In terms of casual staff, a recommendation was made to improve supervision and support. Ms Braun said that this recommendation included adequate skill mix and support to staff who were working in that role.
A recommendation was made about ongoing audits, which were to be conducted to ensure that suicidal risk assessments are completed (which highlights an awareness of escalating risk of suicide). Ms Braun indicated that the suicide vulnerability assessment tool was reinforced in the program and that was audited, and compliance was 100% for all persons coming in through the Emergency Department.
However there appeared to be a 17% failure rate in the AMHU according to the audit.
In respect of the clinical risk assessments there would have been audits in October
However, Ms Braun had no recollection as to the results.
Ms Braun agreed that the thrust of the recommendation in relation to At Risk Categories observations, (ARC) is training staff. Further the purpose is to clarify the importance of writing on the ARC sheets at the time actually cited, rather than an approximation.
There has been focus and attention on that training. Ms Braun stated there are now snapshot audits with review of results monthly and discussion at team level and nursing meetings.
I noted, in a question, that it appeared documents were prefilled, including in 2016, and this was not picked up. Ms Braun indicated that the staff could have done better by auditing more regularly and picking up these errors. This has been emphasised through training and enforcement of procedures.
There was a further recommendation that the on-call psychiatric consultant be immediately notified of any critical incident. In relation to this recommendation, Ms Braun indicated that was not done in relation to Mr Bearham’s death. That falls into the purview of the chief psychiatrist and is not part of her role.
Ms Braun was satisfied that the matter was dealt with appropriately in relation to Mr Lucas’s death.
It was recommended that a formal clinical handover be undertaken by the primary clinician caring for the consumer during that shift, to the primary clinician taking over the consumers care. Ms Braun said the thrust of that recommendation was to ensure adequate, comprehensive, and timely handover to the oncoming shift of RNs. This was designed to ensure that they have enough knowledge of the situation, the background, and any recommendations or changes with treatment and care. Ms Braun agreed that was quite a significant matter.
Ms Braun stated that she and Ms Plant jointly wrote the operational procedure, to set expectations and the agenda of how that meeting would go. More importantly it was to ensure all relevant information was handed over. The morning meeting was a joint multidisciplinary meeting.
In 2015, there was a recommendation in respect of door design, and reduction of anchorage points. Ms Braun explained that given the Mental Health Assessment Unit was only to be operational for a few months and the new unit was to be opened. The CRC report was incorporated to model of care for the ED and mental health interface.
After the attempted hanging of Mr Lucas, the Executive Director requested a point in time review of all fixtures and fittings of inpatient units. That resulted in the Silver Thomas Hanley review. Ms Braun indicated this has now led to a body of works, which is underway to remove the offending hardware and doors.
It was suggested to Ms Braun that nothing much happened between the deaths of Mr Bearham and Mr Lucas. Ms Braun indicated that after Mr Bearham’s death a formal ligature assessment was done, and that there had been consideration of that assessment with the newly designed units.
In respect to potential lessons learned from Mr Bearham’s death, these were considered in light of the design of the new units. However, there was nothing in respect of the existing units, other than the door handle change in social area following Mr Bearham’s death.
Ms Braun said, in respect to the time it took for the CRC outcomes to be distributed after Mr Bearham death, that the recent accreditation surveyors commented that the time it took was far too long.
In relation to notification of Police about Mr Bearham’s death, Ms Braun said that she had been involved with the revision and discussion of the notification policy. Ms Braun said she had attended North-Western Mental Health for sites visits and shared their procedures and interactions with Police following fatal or potentially fatal events. That was in May 2018. Prior to that time, she had not been involved with policy review of that issue.
In March 2017, Ms Braun was an Operational Director. However, she did not recall whether the issue was discussed as an executive group. Prior to that Ms Plant was Operational Director.
Ms Braun agreed that the outcome of the clinical review in relation to Ms Fisher’s death occurred in August 2015. Ms Braun further agreed that she was involved with consideration and implementation of parts of the recommendations.
A recommendation was made that patients awaiting admission to the AMHU should undergo a comprehensive review of their status each day, which included medical and psychiatric status, and that assessment should be clearly documented.
Action was taken in respect of that recommendation, particularly in the new MHSSU when it opened. This included training of staff focusing on suicide assessment, recognition of a deteriorating patient and recording of management as well as clinical presentation. That training is ongoing for staff who are to become staff at the MHSSU or who had previous been staff at the MHAU. The Unit was commissioned in January 2016.
There was an expectation that all staff involved in the Mental Health Interface Program would have additional training in respect of the recommendations.
Miss Braun was unable to explain why that process of daily, comprehensive review of patients did not occur prior to the CRC recommendation being handed down.
Ms Braun acknowledged that the recommendation in relation to Ms Fisher, and indeed a similar recommendation made in relation to Mr Bearham, had been made. Yet, nothing specific was done other than rolling it into the new projects.
Ms Braun agreed that she was alerted to the issue because of the recommendations from those two deaths. As a result, leadership teams ensured that in-service was a regular feature and that there were additional resources for training, and a clinical support officer, and a practice development RN was also provided.
Ms Braun said that whilst the new model of care in relation to operational procedures was occurring, action was being taken on the issue, despite delay on the formalised process.
In terms of the recommendation for visitors to check with staff about items brought into the unit, there is a notice outside of the unit identifying items which are not permitted in it and there is also information provided in a patient information document.
Ms Braun agreed that the recommendations were available as at 20 August 2015 and that the Short Stay Unit opened on 27 January 2016. However, she could not recall whether any interim measures were put in place between those dates. Ms Braun could not recall whether a notice had been placed on the Medical Health Assessment Unit.
Ms Braun confirmed that the only review of fixtures and fittings that she was aware of was in November 2016, after Mr Lucas’s death. Ms Braun accepted that after Mr Lucas’s death it was done fairly quickly but was unaware whether there was any impediment to conducting a ligature audit prior that date.
It was conceded that consideration would have been given to who would do the audit and a business case would need to be completed, as well as funding acquired but there was no impediment.
Ms Braun was aware that there had been no in-patient deaths in a mental health facility between 2002 and when Mr Bearham died. Ms Braun rejected the idea that staff had
become complacent since that time. She also rejected the idea that there had been organisational complacency.
Ms Braun accepted she was made aware shortly after Mr Lucas’s death that a ‘riskman’ report and review had been conducted. This was in relation to documentation process in respect to the clinical risk assessments and the ARC documents. Those changes were cross discipline involving doctors and RNs.
Those changes were still in practice at the time she gave her evidence, as they have improved communication of information between the doctors and the RNs in respect to any changes to the patient’s condition. Ms Braun indicated that the revised form was set to be rolled out shortly after 4 September 2018. Ms Braun also indicated that there has been significant training in respect of the forms as well.
Ms Braun referred to the Clinical Review Committee investigation of Mr Lucas’s death and set out the recommendations made in that report. One such recommendation was to review patient assessment and clinical handover to ensure that every patient in the Mental Health Short Stay Unit is reviewed daily by the medical team, and all patients are to have completed risk assessments.
Further a written and verbal handover must occur every shift for nursing, and daily for medical staff. An additional handover must occur when there is a change in the patient’s condition risk or management plan. A comprehensive written and verbal handover is to be provided at the time of a patient transfer and commencement of treatment is to begin even whilst awaiting an inpatient bed.
Ms Braun indicated that the daily review of patients has been completed and is now effective and was so as of November 2017. However, a meeting of the Chief Psychiatrist and Director of Registrar training considered that daily review was not appropriate and modified that recommendation in the procedures document.
Ms Braun gave a brief overview in relation to the operational drafts for procedural documents for the AHMU and the Mental Health Short Stay Unit. However, it appears that after preparing a draft of the document, it then goes to various committees within ACT Health. This appears to take a considerable amount of time. Unfortunately Ms Braun was unable to say why that was, except to suggest that the governance structure came under intense scrutiny during the accreditation review.
After the accreditation review, organisational change occurred in ACT Health. Health had now been split into two areas. The layers of bureaucracy considering these matters and the time it takes to get through the process is a very slow and onerous process before it becomes published policy.28
In terms of whether the various levels of bureaucracy impede Ms Braun’s work as a manager, she very delicately indicated that the timeframe certainly feels more delayed than they perhaps could be at times.29
In respect to Mr Lucas’s death, the Clinical Review Committee’s report made similar recommendations to those made with respect to the prior mental health deaths. Ms Braun indicated that was concerning and caused alarm because the reports were very 28 Transcript of proceedings dated 4 September 2018 (p 90 – 92).
29 Transcript of proceedings dated 4 September 2018 (p 93).
important documents outlining the treatment and care of people on inpatient wards, and when there are omissions or failures to comply with procedure it is concerning.30
It was suggested to Ms Braun as the same recommendations keep being made, the issue of completed risk assessments still remains, demonstrating that the processes are not optimal or not working. Ms Braun agreed that there is occasion when they have found not to be working. This highlights the need to continue focusing on compliance with requirements in relation to documents.
Audits and emails to staff about requirements were sent to signify the importance of policy. Ms Braun stated that they did not just wait for the CRC recommendations, they sought immediate changes with the processes which was reviewed, audited and embedded in the procedures.
Ms Braun agreed that the recommendations by the CRC review all essentially dealt with observations in respect to ARC observations. Ms Braun also agreed that the main focus was recommendations about risk assessment and observation. It was noted that then Chief Coroner Cahill in 2004 also made a similar recommendation.31
Ms Braun indicated that after Mr Lucas’s death the clinical director, the consultants, and registrars all met to consider what was and wasn’t working. Ms Braun indicated that updating ARC observations was clearly recognised as a focus of concern and that continuing audits and education was required in this area. The issue appears to also involve staffing issues, training qualifications of RNs looking after patients, casual staff and the like.
Other recommendations included there being both a written and verbal handover occurring at shift change, particularly in relation to the deteriorating’s mental state of the patient. The thrust of the recommendation is to ensure there is a written record of that change. In relation to transferring of a patient from short stay unit to the AMHU, there is now a handover checklist detailing patient’s condition.
Another recommendation was to commence treatment, rather than defer it, whilst waiting for an inpatient bed, such as happened to Mr Lucas and Ms Fisher. That recommendation was implemented so that the clinical director, in consultation with the consultant psychiatrist in the Short Stay Unit, would plan and treat a patient accordingly, if there was to be a delay.
The recommendation stated that all patients coming into the MHAU must be reviewed by a receiving consultant psychiatrist or registrar, with reviews on weekends and public holidays to be prioritised on a clinical need basis.
In audits conducted in relation to failure to complete CRA, Ms Braun indicated it seemed that the issue lies at the level of doctors and nursing staff not completing the processes appropriately.
In respect to the failure to advise the RN looking after Mr Lucas of the changed ARC score, the recommendations have been met by team meetings, discussion of the recommendation, and reinforcement of timely and effective communication. There was also work in respect to changes to the CRA and ARC. Those changes occurred directly after Mr Lucas’s death.
30 Transcript of proceedings dated 4 September 2018 (p 93).
31 Transcript of proceedings dated 4 September 2018 (p 96).
In respect to the recommendation in relation to level of risk, it has been acknowledged that patients who require a higher degree of supervision should be quartered in corridors closer to the nursing station. Having said that, it was also acknowledge that is a very difficult process given the occupancy rate is generally high in the unit.
In terms of the design of the door and the associated ligature points, Ms Braun noted that an external risk assessment was conducted by consultants in April 2017. The committee approved the report into September 2017, and in December 2017 a request was made to remove the ensuite doors in the AMHU. This removal commenced in January 2018 and was completed in May 2018. Ms Braun also recognise that it wasn’t until March 2018 that approval to engage the expert consultants was granted.
It was suggested to Ms Braun, by Counsel Assisting, that it was not until after the accreditation process, and the finding of extreme risk was made in late March 2018, that the issue of altering the doors received any priority. Ms Braun stated, “that the timing of the accreditation reviewer’s recommendations regarding the ligature minimisation works at AMHU does closely correlate with the funding being approved.”32
Ms Braun also agreed that the expected completion date for the entire project was 31 August 2018 and that completion had not yet been met. Ms Braun expected that the project would be completed by the end of 2018. The delay to the works had been because of the complexity of hardwiring the doors and integrating it into the system.
Ms Braun agreed that the recommendations register, which maps all recommendations, is reviewed monthly. Ms Braun also agreed that the same themes keep popping up in the recommendations, which she has picked up at times. Ms Braun indicated that those issues receive high priority and urgent discussion.
Ms Braun indicated that with the issues which keep ‘popping up’, the various committees look at ways to improve the system.
In respect to the open and active recommendations, which are part of a capture or map of outstanding recommendations, there are none from then Chief Coroner Cahill that Ms Braun was aware of.
Re the death of Ms Douch
In respect to Ms Douch’s CRC it appeared that the document contained all recommendations in respect to her death. The thrust of the Committee’s recommendations where patients who have complex comorbidities including medical and psychiatric disorders, as well as chronic pain, and substance use disorders, is for a multidisciplinary approach is the considered approach.
In terms of the implementation of the CRC recommendation, apparently the report had fallen through the cracks and was not actioned for a significant period of time. It came to light that no action had been taken until after the accreditation report was submitted, notifying extreme risk. Ms Braun said that it’s not that nothing had happened it’s just that it had not been formally closed.
Ms Braun indicated that, in reference to the recommendation of a multi-disciplinary meeting, the Consultant Liaison Psychiatry Service will only attend the multidisciplinary meeting when requested to do so.
32 Transcript of proceedings dated 4 September 2018 (p 109).
Ms Braun was of the view that more collaboration and standard involvement of multidisciplinary specialists occur and it’s more a getting to know the clinicians in the other specialties.
In terms of the multidisciplinary approach, the recommendation states “risk assessment and well communicated management plan with involvement of the patient, family, carers and GP that also includes predictive planning, clear referral pathways, escalation management plan and discharge planning.”33
Ms Braun indicated that, in terms of the mental health areas, active involvement with the support of the admitting unit and treating team are all involved with planning the clear referral pathways. It is up to them to then consider involving other team members.
This would also include discharge planning. Action on this recommendation would have been undertaken by the clinical director at the time, with the consultant liaison team.
There was a recommendation in relation to specialist psychiatric assessment, close monitoring, and routine follow-up for complex patients following an intentional and potentially fatal overdose. This has been followed up with specialist assessment referrals, risk assessments from the clinical liaison team to undertake suicide vulnerability assessments, and then advice to the admitting team.
The recommendation for mental health patients situated in a general ward included skilled staff including trained mental health RNs and assistants in nursing. Ms Braun indicated that where patients on a general ward require increased patient care, the consultant liaison team feeds back to the inpatient team and will discuss the requirements necessary. If it was deemed necessary, the nursing resource office would provide a suitable qualified person to fill that role.
Since the recommendation was made in February 2017 there has been further education for staff on those wards. There is now a training calendar in place, where a clinical RN educator, or one of the medical staff, assists in up skilling those nursing staff in mental health training.
In relation to Ms Douch’s death, aside from the CRC process, Ms Braun was not aware of any other actions occurring as a result of her death. Ms Braun accepted that, had there been any investigational review, something would have come to her attention following March 2017.
Ms Braun agreed that after a CRC investigation, recommendations are distributed to the division and is reviewed through the mortality and morbidity committee.
Ms Braun was not aware whether the CRC made any recommendations in relation to the notification of Police about deaths, or anything in relation to suicide notes nor patient self-admitting thoughts of harm by hanging, nor any recommendations in relation to personal searches and property searches.
In relation to the March 2018 accreditation audit, Ms Braun indicated that there was a survey of TCH undertaken by the Australian Council on Healthcare Standards between the 19th and 23rd of March 2018. An output from that survey was set out in a document called “not met report”. Ms Braun agreed that the document summarises those things which were not met during the survey for accreditation.
33 Transcript of proceedings dated 4 September 2018 (p 117).
That document was exhibited before me, and indicated that there were parts of the organisation which were criticised, including significant concern around a number of issues in mental health. These including the number of suicides over the past three years, which had not had a robust review, nor had strategies been implemented to mitigate the risks.34 The document noted that the survey team assessed the risk level as extreme.
The comments made in relation to the risk by the surveyor include the following “the delay in immediate actions posts suicide and the delay in undertaking regular – regular ligature point audits and implementing the results of the engineers report into ligature points placed the patient consumers at extreme risk”35
The recommendation from the surveyor was that the hospital was to complete an immediate, independent, external review with inpatient units to assess the level of safety and the risk to the consumers. Ms Braun indicated that comment was the Genesis of the review undertaken by Northwest Mental Health.
The engineers report was completed in January 2017, following Mr Lucas’s death in 2016.
The surveyor also commented on the mental health deaths saying “despite all the recent work to address the national safety and quality health service standards in general that the organisation has undertaken, there is significant concerns raised by the survey around the five suicides over the past three years within inpatient units of the health service. Four deaths in mental health and one death in a general medical ward. There was no immediate commissioning of any external review for all four deaths, nor was there a robust RCA undertaken in three of the cases. There was some form of general feedback with some suggestions, but this failed to make any significant impact. There was a report undertaken by an external architect on ligature points in January 2017, and a Gantt chart has only been developed to commence in February or March 2018, over 12 months post the review. There appears to have been no regular ligature point audit undertaken, nor was there any action plan done to implement strategies to prevent further cases.”36
It was suggested that the surveyor made two recommendations. The first being immediate action to reduce the high risk of ligature points, and the second to establish a mental health review advisory body. Ms Braun indicated that they were also in the process of moving the ligature points, and if the first remediation plan had been acceptable the doors would have already been removed by the time of accreditation. It is clear that the request was made in December 2017 and work commenced in January 2018 and it was not until May 2018 that it was completed.
Ms Braun accepted that one of the considerations which was brought to the Chief Health Officer’s notice was to completely shut down the AMHU. There was a report generated to the Chief Health Officer Paul Kelly, in response to the not met report and extreme risks identified.
Ultimately after considering other options it was decided it was not in the best interests of the people of the ACT, who are at high risk, and in need of acute inpatient mental 34 Transcript of Proceedings dated 4 September 2018 (p 124).
35 NSQH Standard Survey ‘Not Met Report’.
36 Transcript of proceedings dated 4 September 2018 (p 125).
health care, to close the unit. Dr Kelly ultimately agreed that the unit could remain open whilst mitigation work continued.
Ms Braun agreed that by the time the North-Western Mental Health team arrived a great deal of work had already been done in respect to the work required. It was those works, reports, policies and procedures which the reviewers considered were comprehensive and detailed.
The report further made comment about the governing structures and said this “perusal of the ACT Health governance structure suggests lines of accountability between clinical governance structures of …mental health and the corporate effective structure lacks clarity. The reviewers understand that steps are being taken to review the overarching corporate structures that govern mental health. Nevertheless, in the view of the reviewers it is germane to note the manner in which this lack of clarity has affected incident reviews and the implementation of recommendations arising from the investigations undertaken. The relationship between the morbidity and mortality committee of mental health and the ACT Health quality governance and risk division constitutes an important representative example. The nature of the decision-making process and the accountability structures involved in relation to the development of business cases and the identification of financial resources to implement the recommendations of the morbidity and mortality committee was not clear to the reviewers. Confusion about these processes and the lack of a direct line of accountability appears to have delayed the process of improving ligature safety in particular.”37
Essentially, there was a significant level of bureaucracy involved in commencing works, particularly in relation to ligature risk minimisation. Ms Braun indicated that the Executive Director must report to the Deputy Director-General, a financial business case must be provided that can fit within the existing budget which would then go to the Director-General’s counterpart in corporate finance. There may also be cabinet briefs that are required as well as various executive sign offs in order for this to occur. NorthWestern Mental Health reviewers stated this process was quite confusing and complex, and their comments mirrored the ‘not met’ recommendations in standard 1, which is governance.
Ms Braun was unable to clarify how the new structure, which was to occur on 1 October 2018, would look and how it would work, as those things were still being worked on.
That mainly relates to the corporate and financial side, rather than the clinical side. Ms Braun opined that the recommendations made by North-Western Mental Health will be beneficial to the mental health division as a whole.38
Ms Braun said she was aware of how Ms Fisher had died, and it was suggested to her that the evidence from Dr Roderigo, RN Matsika and Dr Wood all stated that if they had seen her wearing a belt they would have either removed it or brought to the attention of someone. It was suggested to Ms Braun that Ms Fisher had a belt on her dressing gown and wore it into the ward on admission. Having been advised of that factor Ms Braun was asked what policies or processes have been implemented to mitigate against the risk of that happening again.
Ms Braun indicated that there is a new CRA form which specifically mentions particular items which could be used as ligatures. It was noted that on the document there is no 37 Transcript of proceedings dated 4 September 2018 (p 129 – 130) [my emphasis].
38 Transcript of proceedings dated 4 September 2018 (p 132).
mention of belts or cords. Ms Braun indicated that it may well be in the operational procedure but not on the form, and that is something that can be taken under advisement to be include in the form.
Ms Braun agreed that the operational procedure document where it refers to search procedures is the ideal place to expressly speak of belts and the like.39
Counsel Assisting raised with Ms Braun that a number of witnesses who gave evidence in the inquest in relation to searching patients, clearly did not well understand the search policy and the legality of that policy in relation to searches of patients in the AMHU.
Ms Braun accepted that operational procedures is a lengthy document and that the process is not always well understood and agreed it could be a focus of increased awareness and training for the future. Ms Braun indicated that the document is multifaceted and also involves various points in time and the particular patients’ needs.
It is not a blanket rule.
“if it is determined that the situation represents an imminent danger to the person or others, then a search of the person may proceed without consent in order to provide a safe environment for themselves, other people and staff. Ms Braun agreed and stated that would always have the involvement of the treating team and the consultant psychiatrist.”40
The document, in relation to ligature risk management procedure, is a new document issued on 2 July 2018. However, there was collateral risk assessments being completed prior to that document being issued. Those included audits in respect to ligatures and ligature points. An action plan was completed and applies throughout the hospital facility. These are relatively new procedures following an investigation.
In terms of ligature cutters, they have been in use and have always been on the MET trolley. Staff were aware that they were there.
Ms Braun accepted that the clinical risk assessment policy and ARC was in place at the time of all four deaths. The policy has now changed however, the form still remains.
There are plans to change the ARC forms which will be workshopped with staff and will have a focus on engagement by the staff as to what should be on the form.
Ms Braun stated that there will be training in relation to the new risk forms and observation forms in that regard.
40 Transcript of proceedings dated 4 September 2018 (p 135).
increased numbers of RNs. Ms Braun indicated she will consult with the executive about increasing numbers of RNs.
Ms Braun agreed that there are scientific studies which show increased therapeutic engagement with patients is a key factor in reducing suicide risk. 41
Ms Braun identified that there are some new processes, such as a worksheet for use by RNs to enter information, which will ultimately be part of the patient’s clinical notes on the database. This is working well in the clinical setting.
Ms Braun indicated that she was aware of the document, which sets out the policy in respect to a consumer’s death, and suggested that if it was she on call she would refresh her memory and go step-by-step through it and identify to staff those procedures based on the policy.
Ms Braun accepted that staffing resources require careful rostering and must come within budget. It is a difficult exercise particularly with unplanned absences and the like.
Ms Braun identified that the Christmas period was difficult, as described by Dr Gray.
However, that has now changed, and allied staff members come in over the Christmas period so that patients can receive therapeutic treatment. That was largely done as a response to the previous Christmas, which Dr Gray had described.
Ms Braun identified that staff do work double shifts. However, there are options for parttime staff, relief nursing staff and, of course, agency staff when there is no available hospital staff to deploy to the area. Ms Braun stated that in her experience, after 2016, those shortfalls where agency RNs are used are generally filled by those who readily work in the Adult Mental Health Unit and have mental health experience.
Ms Braun was told that Dr Ahlin gave evidence that he felt he was always prioritising between patients and bed numbers. Ms Braun said that this did not surprise her. In terms of assessing patients for admission, Ms Braun indicated that everyone is assessed, and the assessment is done appropriately, and after due consideration. This will then instruct as to whether the person requires the admission or not.
Ms Braun was asked questions in relation to recommendations. She indicated that in 2015, the number of RNs at each shift was nine in the morning, nine in the evening, and seven overnight. That number has now increased to 11 in the morning, 11 in the evening and nine or 10 at night. That is an increase for the AMHU. Ms Braun also indicated that she has increased the hours of RN educators as well.
Ms Braun was advised, in relation to Ms Douch, that the suicide note was overlooked by some staff. Despite the Emergency Department Doctor making a note of it and despite it being noted it in the clinical notes, Dr Regna saw Ms Douch and was unaware of the note, and he indicated in evidence that had he known about it he would have altered the course of her clinical consultation. Dr Ahlin suggested that information should be prominently displayed in the clinical notes. Ms Braun was asked to comment on whether she could suggest strategies to mitigate this risk.
Ms Braun suggested that communication was important, and also advised that ACT Health has now signed up to the lifespan systems approach, with new Emergency Department guidelines to be implemented. It was envisaged that this would ultimately 41 Transcript of proceedings dated 5 September 2018 (p 146).
“ensure there is an integrated systems approach with how ED do their work.”42 Ms Braun went on to say that over the course of the next three years the entire TCH Health Services will focus on training and improvement in mental health literacy for all staff.
It was suggested to Ms Braun that, as a result of an issue arising out of a New South Wales Inquest, a key suggestion was for oximeters to be provided to inpatients. Whilst trials are still ongoing in relation to that particular apparatus, it may be an option that ACT Mental Health can consider once a trial period has finished.
Ms Braun indicated that despite the tragedy of the four deaths, they have cared for many thousands of people during the lifetime of the unit’s operation. In terms of safety Ms Braun said “in light of the independent review that we have just had in working with the recommendations that have come from that and once the ligature minimisation works are complete, I am very confident that our unit is as safe as it can be and compared to other units, it will be above and beyond in terms of fixtures and fittings to try and ensure ligature minimisation… We will be potentially the gold standard.”43 Impression
I found Ms Braun to be a very impressive witness. The evidence she provided to this inquest was extensive and very helpful in understanding the processes in place at the time of the deaths. Importantly her evidence outlined the processes the Directorate has undertaken to mitigate further risks to inpatients at the mental health facilities at the TCH campus. I thank her for her assistance.
David Ranson
Professor Ranson is a forensic pathologist and Executive Director of the Victorian Institute of Forensic Pathology. Professor Ranson provided a report which was exhibited as CD5.
Professor Ranson was provided with photographs of the body of Ms Fisher, and indicated that it is difficult to evaluate the precise time of death looking only at the photographs. Professor Ranson discussed the discolouration of the skin after death, which is called lividity. He described what influences the lividity, including gravity and also contact with skin on a hard surface. Moving a body would change the distribution of the blood, and therefore the areas of lividity. Professor Ranson indicated that until lividity is fixed, which can take between 8 and 12 hours, those areas can change.
Professor Ranson indicated that it is not a precise science, and the lividity observations can take anywhere from a few tens of minutes after death to hours to become apparent.
Professor Ranson indicated that the patchier appearance of discolouration speaks about the time of death, approximate to the uniform discolouration which will ultimately occur.
42 Transcript of proceedings dated 5 September 2018 (p 156).
43 Transcript of proceedings dated 5 September 2018 (p 158).
Professor Ranson indicated without accurate measurement and assessment, of how a person feels in terms of their periphery is a very unreliable determinant of the actual core body temperature.
Professor Ranson indicated that the broader the ligature, the wider the area for supplying the neck, and lowers unit pressure on the neck area as opposed to a narrower ligature. Professor Ranson indicated that both can cause death rapidly, it very much depends on the circumstances and the degree of force that is applied.
That degree of force depends also on the force exerted by the person’s weight. If they were fully suspended it would be more significant than if they have their feet on the ground, knees bent or kneeling, or were sitting. It would then be proportionally less force to the neck.
In terms of time of death, Professor Ranson opined that a forensic pathologist would be interested in determining the existence of true lividity, the determination of core body temperature and those sorts of features. Professor Ranson said that if you have a high level of precision about those issues, the time of death becomes easier to calculate.
However, none of those tests were sufficiently reliable or precise for him to draw a definitive conclusion as to the time of death. Professor Ranson opined that in terms of mottling, it can take tens of minutes and some literature would say hours. Whilst some literature would say you can get mottling at a much earlier stage. There is an enormous variation in the pathology literature, and from his experience determination with any precision in relation to minutes or even tens of minutes is very difficult in this area.
Professor Ranson agreed that he could not reach a probable conclusion as to whether the ligature was applied before 09:15 hours or after 09:15 hours. Of those two possibilities, the paucity of the information available as to her condition did not allow him to conclude one way or the other.
In cross examination, Professor Ranson was questioned about Dr Cole’s finding that Ms Fisher was cold centrally and peripherally. Professor Ranson opined that it is difficult because it depends on what is meant by ‘cold’. Scientific measurements are taken of the core body temperature to indicate just how cold the body is. If a person was truly cold centrally that would indicate they had been dead for a longer period.
Ultimately, Professor Ranson opined that the observations of Dr Cole and others about how they found Ms Fisher including her temperature, lividity patterns and the like could not assist him in determining with any great precision the time of death.
Michelle Hemming
Ms Hemming is the Executive Officer for Mental Health, Justice Health and Alcohol and Drug services for the ACT. She has held that position since 2011.
Part of Ms Hemming’s role is to manage the Executive Director’s office, coordinate all correspondence and government business for the division, which includes complaint processes through the Minister’s office. That also includes ministerial briefs, question time notice briefs and the like. Ms Hemming is also responsible for the release of all information for her division.
Ms Hemming also performs duties as a liaison for legal and criminal matters which impact the division. One of her duties is to interact with ACT Police in relation to their investigations, particularly the death of a person who was at the time of that death a patient of ACT Mental Health.
In questioning, Ms Hemming was referred to the current operating procedure in relation to ‘When a Death Occurs’ which outlines the criteria for notifying the coroner’s office in that regard.
Specifically, Ms Hemming was taken to a paragraph in the protocol concerning request for statements from members of staff. Part of the policy in relation to that issue is that staff are told that there is no obligation for them to participate in an interview with Police.
If there is a request from Police to give a statement, they should contact the Medicolegal Unit. That Unit is not a reference to her office and is located at TCH.
The MOU between the Hospital and the AFP, as well as other services, reflects the protocol outlined above. That protocol includes that any release of information should be requested in writing and be provided to the Executive Officer, which is Ms Hemming.
There is also a referral to the insurance authority and the ACT Government Solicitor (ACTGS). Ultimately, Ms Hemming prepares all the material that she expects, through her experience, will be required by the Coroner’s team and gets it together in one place.
Ms Hemming would also, if requested, ascertain the staff working at the time and place of the death and identify those staff from the roster. Ms Hemming can also ascertain when they’re working, and therefore available to give information to Police.
Ms Hemming identified that she then has a standard email she sends to the staff advising them of the process of either providing statements or speaking with Police. Ms Hemming indicated that she usually uses the words ‘cooperation is usually recommended’.
Ms Hemming also identified that it is her usual practice to ask the Coroner’s office or the Police to identify the specific issues to be addressed in the statements.
Ms Hemming said she also explains to staff that they can engage their own solicitor and that ACTGS represents the territory rather than the employee.
Ms Hemming identified that if the staff member opts to provide a written statement, the usual practice is that it is done through ACTGS, but the staff member could write it themselves or work with the Government Solicitors.
Ms Hemming’s involvement is one of organising records to refresh memory, organising time with Government Solicitors and the like. Ms Hemming also has a supporting role with them as well.
Ms Hemming described how she would assist with access to a scene for the purposes of investigating a death with the Coroner’s team and the Australian Federal Police. In terms of what occurs now, she said that where the incident or death occurs, that area is closed off and access is no longer available to any person.
The ‘when death occurs operational procedure’ is followed, the Coroner’s team is contacted, and they are then provided with an opportunity to come and look at the area.
Liaison is done so that the investigation is not impeded but at the same time the room
can be refreshed, so that incoming patients can use the room which is no longer needed by the deceased. If the person died in the AMHU, the body would remain in-situ until Police had examine the scene. All personal items belonging to that person would also remain in-situ. That was also the case in 2015 and 2016.
There is a new operating procedure in relation to a person who has not died but is likely to die. There is a process where the specialist consultant, either in the unit or on-call, would contact the ICU specialist regarding the prognosis of survival. Based on that information a Coroner’s team would be advised of the self-harm and that if there is a high probability of death, then they would close down the room, notify the coroner, compile the medical records, invite the Police in so that they can see the area where the self-harm occurred. Ms Hemming stated that was the process that was followed in 2016 regarding Mr Lucas.
Ms Hemming outlined the meeting she had with Constable Norman in respect to a criminal matter and also Mr Bearham’s death. Ms Hemming agreed with part of what Constable Norman said in relation to her experience of staff being very afraid to speak to Police, particularly in relation to a coronial process and that also the professional bodies get involved and frustrate the process.
Ms Hemming however, denied that a witness refused to assist in the matter of Bearham and denies telling Constable Norman so. Ms Hemming agreed with the recorded conversation that she had with Constable Norman and the issues canvassed in relation to witness statements.
Ms Hemming indicated that she had a good rapport with staff and spends considerable time working with them and encouraging them to be part of the process. She also accepted that she said that self-harm is a clinical incident for her purposes, and that if a person dies Police are notified. Ms Hemming agreed that if a person has committed self-harm and has not yet died, Police would be notified about their survival probability.
Ms Hemming told Constable Norman that the primary focus is on patient care not investigation.
Ms Hemming also advised that the issue in relation to Mr Bearham’s death, where the code blue was not called, was resolved. The issue involved the relay systems and the mechanical fault had been corrected.
In cross-examination, Ms Hemming accepted that she was the Executive Officer in mental health during the time of the deaths of Mr Bearham, Ms Fisher, Ms Douch, and Mr Lucas. Ms Hemming was responsible for the coordination in relation to Mr Bearham and Mr Lucas. Ms Hemming was jointly responsible with the Medicolegal team in relation to Ms Fisher’s death and she was also the coordinator for Ms Douch’s death.
In terms of the operational policies in relation to where a death occurs, Ms Hemming was of the view that reviews were undertaken on a rotational basis and that consultation is what prompts a review of the protocol.
It was suggested that the consultation in respect of that policy did not involve Police, that was denied.
Ms Hemming agreed that there is no statement in the protocol encouraging staff to do all they can to assist the Coroner in the exercise of their judicial function. Ms Hemming agreed that it would be helpful and beneficial for staff to have such a statement in the document.
Ms Hemming agreed that there is a different tenor in the wording of the document encouraging family members to speak with Police, than there is for staff. However, Ms Hemming did not agree that it meant that there was a lack of encouragement to staff to assist the coroner’s process.
It was also suggested to Ms Hemming that a rewrite of the email that she would normally send with a more positive focus on assisting the coroner would be beneficial. Ms Hemming also agreed that placing ‘usually recommended’ in the email concerning cooperation should be removed.
Ms Hemming agreed that the MOU which binds Police and ACT Health and other signatories does not bind the Coroner’s Office. Ms Hemming stated that the predominant preference was that staff do written statements.
Ms Hemming also agreed that the MOU does not prevent Police asking for contact details of staff members, nor does it prevent Police from requesting staff participate in interviews.44
Ms Hemming advised the percentage of written statements represents 95% and interviews 5%.
Ms Hemming agreed that she had stated that it may be traumatic for someone who had been caring for a recently deceased person to give a record of conversation to Police, and that providing written statements lessons the trauma to them.
In relation to the document ‘New Incidents Reportable to the Executive Director of an Intervention Following Death, Mental Health Justice, Alcohol And Drug Service’, Ms Hemming agreed with Counsel’s suggestion that the document was prepared after Mr Bearham’s death but was not formalised until after Mr Lucas’s death.
Ms Hemming stated that this document was part of a normal suite of policies and procedures that staff are aware of and advised to be familiar with. In terms of training she was unable to make a comment.
Ms Hemming agreed that she was the designated coordinator between Mental Health and third parties such as the Australian Federal Police. In her view it was that coordinated approach was important and beneficial in relation to coronial matters.
Ms Hemming said her approach is to identify those who were on duty at the time by examining the staff rosters and the like and that can take as little as an hour but certainly within a day. Ms Hemming stated that requests from the Coroner and Police are actioned immediately once she receives the email.
Ms Hemming identified that after receiving a request for information she would either action it or then forward it to the Government Solicitor. It did not necessarily have to be in that order, and generally she apprehends the necessity for this type of information once death has been notified. Ms Hemming stated the most pressing of those matters would be the request from Police.45
Ms Hemming qualified that request as to the Mental Health staff only does not include the Medical Emergency Team or the wardsman who are called to the code blue or code 44 Transcript of proceedings dated 5 September 2018 (p 219).
45 Transcript of proceedings dated 5 September 2018 (p 224).
black. Ms Hemming said she can obtain that information if required. Her main focus is the Mental Health staff as Jenny Broome would get the rest of the information.
Ms Hemming had indicated that when requested by Police to provide contact details for any potential witnesses she tells Police that she can coordinate interview and that she usually takes this approach. That’s on the basis that staff can be traumatised by a death and she has the opportunity to reassure them of the process beforehand.
Ms Hemming indicated that she has never provided contact details of those witnesses to Police. Ms Hemming said she has not done so because she has never been asked to. Ms Hemming contrasted Constable Norman’s request as his desire to speak directly to witnesses rather than requesting contact details. That is despite both Constable Norman and Constable Best stating that they felt there was a lack of cooperation from Mental Health in relation to the provision of statements.
In relation to the email Ms Hemming sends to potential witnesses, she waits for them to contact her rather than the other way around. If they do not contact her, she contacts the direct managers of those persons and asks them to bring the request to their attention.
Ms Hemming indicated that she does follow-up on emails which may include the operational director for those staff members but that may take some time. In respect to Mr Acs, Ms Hemming did not contact him as he was not working at the time of the incident and was not identified as someone who would be required. It is her practice to wait for the request from Police and then action it.
Ms Hemming agreed that Mr Acs was not asked to make statement until three years after Mr Bearham’s death.
Ms Hemming gave evidence that it is her role to facilitate the making of statements, where she arranges appointments with ACTGS she then reviews all statements for grammar and spelling mistakes. The statements are then provided back to ACTGS for review and then provided back to her for her signature. The review is conducted to ensure that all issues listed in the request are included in the statement.
In answer to a question from me, Ms Hemming stated that members of staff have the option to prepare the statement themselves or they can speak with the Government Solicitor who helps facilitate the writing of the statement, which is then provided back to the staff for review and edit. The ACTGS may change anything they choose. Some witnesses choose the same process with their own solicitor.
Ms Hemming indicated that she attends ACTGS when these witnesses are making their statements. Ms Hemming agreed that there are often a number of different versions of statements generated in this process before a final version is signed off and then sent to the AFP or the Coroner’s team.
Ms Hemming was referred to Dr Cole’s statement, and also his early recorded interview.
Ms Hemming agreed that memory would be better closer to the incident as it fades with time. Ms Hemming accepted that it would be better for statements to be provided at an early time, as it would be a more accurate reflection of what occurred.
in a better position than a lawyer. Ms Hemming said she would not disagree with that proposition.
Ms Hemming indicated that the officers request information, a statement is prepared, they read the statement and if they have any further questions, they need to write those questions down and provide them to her. Those are then provided to the witness for a response. Ms Hemming agreed that it was her role and objective to coordinate responses by providing information to the Police in such a way that staff well-being isn’t detrimentally affected. That is one of the considerations she undertakes.
Ms Hemming indicated that the other consideration is that the staff have the opportunity and choice to undertake how they provide the information, that they can have access to the information to inform themselves and reflect upon what happened, so they provide a comprehensive statement.
Ms Hemming did not accept that she influenced the preference of staff as to how they make their statements and stated that she is very clear in the choice she gives them.
Ms Hemming was asked about an email from 15 January which states “as employees of ACT Health, the Territory is legally liable for your actions”.46 Ms Hemming denied that this could be a statement that could be seen as encouragement for them to speak to ACTGS and not directly to Police. I noted that this statement needs to be clarified as it could be misleading, and Ms Hemming said she would consider it.
This process documents the incident, put it aside and can be pulled out when needed.
Ms Hemming was questioned in response to her answers about the failure to Police contact details of witnesses. Ms Hemming agreed that she did make comments to Constable Norman regarding contacting staff, and said that it was inappropriate in some circumstances.
Ms Hemming agreed that Mr Bearham attempted suicide on 4 January and his death occurred on 6 January. On 15 January she requested witnesses give statements and her official request was made on 22 January. Part of that email was a request that staff contact her by 27 January in respect of which type of statement they wished to participate in.
Ms Hemming was taken through the statements by Constable Norman in relation to Mr Bearham’s death. The first issue was the sanitisation of staff statements through the medicolegal office of ACTGS which acts on behalf of the Territory and not on behalf of staff. Ms Hemming denied that. It was suggested that staff may wish to say something adverse about the Mental Health Directorate and may not feel free to do so because of the vetting of this statement by ACTGS solicitors and herself. Ms Hemming stated that she does tell the staff members that if there is anything good bad or ugly it needs to be said whether it’s adverse or not.
Ms Hemming acknowledged in answer to a question, that a policy that staff who witness an incident referrable to the coroner should make statements to the Police, which include tape recorded conversation with Police, would be beneficial. However, Ms 46 Transcript of proceedings dated 5 September 2018 (p 233).
Hemming said she was unable to answer whether it should be a condition of their employment as she is not the person to ask about that matter.47 Ms Hemming did proffer her own opinion, stating that she is not sure it would make a difference because they already do provide statements.
Ms Hemming accepted that in the policy provisions ‘When a Death Occurs’ is, at present, unclear about the options which may be exercised by staff. Ms Hemming was of the view that it would be beneficial to have those options available in the document.
In relation to Ms Fisher’s death, Ms Hemming was away at the time, and the statements in that matter were dealt with and coordinated by Ms Broome and the Medicolegal team.
Ms Hemming was asked about the number of statements which were all sent to Constable Best as well as Constable Best’s comments in relation to the number of statements taken (27 statements),48 and her view that some were not necessary after she had reviewed them. Ms Hemming agreed that it appears that speaking to persons and getting information to and from them expediently would be beneficial and would help to narrow the focus of who Police needed to speak with.
Ms Hemming was taken through the passage of evidence from Constable Reynolds.49 Ms Hemming agreed that many of them were signed in late 2017 and were not provided until February 2018. Ms Hemming accepted that all the statements, except for Dr Modak’s, were signed more than 12 months after the death of Mr Lucas.
It was suggested to Ms Hemming that several of the staff, in cross examination, said they did not recall being offered the opportunity to speak to Police. Ms Hemming stated that it did not surprise her. Although she did say in relation to Mr Ngor, that she was surprised that he said he wasn’t offered the opportunity and she was unaware that he wished to speak with Police.
Likewise, RN Nkomo said that she would have spoken to Police as she had nothing to hide but would check with her supervisor first. Ms Hemming stated she could not recall whether she was given the opportunity to speak with Police directly. An objection was raised by Counsel for the Territory, stating that there was no request made by the officer to Ms Hemming.
Ultimately, it was agreed by Ms Hemming that the policy about what happens ‘When a Death Occurs’ could be updated and clear specifications provided particularly in relation to witness options regardless of where they worked.
Ms Hemming stated that the tragic deaths we are dealing with in this matter have caused policy to be changed, and there have been no deaths or significant incidents of self-harm at AMHU since Mr Lucas’s death.
In respect to consultation regarding operational procedures, a document was produced with a bundle of emails and a table attached to it. Specifically, in relation to information provided to ACT Police and the Coroners Unit, the document indicated that the provision of personal health information must not occur about the patient. The process is that the provision of personal health information would not be provided to Police immediately, but after receipt of a subpoena, a process will be undertaken to provide information as requested after engaging in a process of examining the notes. I note that 47 Transcript of proceedings dated 6 September 2018 (p 251).
48 Transcript of proceedings dated 6 September 2018 (p 254.30) 49 Transcript proceedings dated 6 September 2018 (p 258).
the legislation has now changed, and the coroner can make a direction in relation to request for medical records.50 Clare Gallagher
RN Gallagher is a clinical RN Consultant in the MAPU from 2011. During the period of when Ms Douch died, she was on leave. RN Gallagher gave evidence about the changes in the handover process following Ms Douch’s death. One of the changes was that the multidisciplinary team meeting now included the Drug and Alcohol Team, and the Chronic Pain Management Team. The psychiatric consultation and liaison team was not included, as they meet at the same time elsewhere. Arrangements were made whereby they come straight to the unit following their morning hand over around 09:00 hours. The Chronic Pain Team does not come to the meetings, but a one-off meeting will occur if there is a patient on the unit requiring their assistance.
In respect to Ms Douch, at the time of her death once the Consultant has reviewed and cleared a patient the consultation has been finalised. It would require a re-referral to that service. Changes have now been made so that an open referral continues, and if the patient requires further consultation that is available without a further request.
In respect of training, the program has now been more coordinated since Ms Douch’s death. There has also been further restructure of the handover process with a flash handover conducted between team leaders from the outgoing shift to the incoming shift.
There was also a form change, noting on the top of the form any risks staff should be alerted about.
In terms of information, particularly things such as suicide notes, are kept in the front of the file of the patient’s, so they are obvious as soon as a file is opened.
RN Gallagher stated that she was aware of Mejo Galenic’s death and had read the coroner’s recommendations. In relation to the recommendation about the handover, RN Gallagher stated that there was a review of the handover sheet and it was completely reformatted after his death.
In respect to the second recommendation about standard operating procedures, RN Gallagher indicated that there was no new SOP but 2 new clinical forms were created, one of them with information that would then go to the Police when a patient absconded, and the other is a document which collects information on a patient if they think that they are at risk of absconding.
In relation to the third recommendation about egress and access to general wards by psychiatric patients. RN Gallagher said nothing was done as it was not possible to do anything about that recommendation.
In relation to the fourth recommendation about addressing particular circumstances of patients with psychological or psychiatric conditions being housed in units other than the psychiatric unit such as MAPU, nothing appears to have been done in regard to that recommendation.
RN Gallagher was not the CNC at the time of Ms Douch’s death but was aware that there was a Clinical Review Committee investigation conducted and it was her role to consider and implement recommendations from that investigation.
50 Coroners Act 1997 (ACT) s 19B.
RN Gallagher indicated that the recommendations have been implemented in so far as the multidisciplinary team meeting now includes drug and alcohol service and also the psychiatric liaison team where required. RN Gallagher indicated that Dr Swaminathan started the process himself. Those recommendations were implemented in February 2018.
In terms of the recommendation for skilled mental health staff being on that Ward. The implementation of that recommendation was through general trained staff with an interest in mental health. There is some scope for trained mental health RNs working on the Ward. However, given it is a general medical ward, some trained mental health RNs cannot care for purely medical patients unless they upskill training in general nursing.
There is also now training in the suicide vulnerability assessment tool, used to identify those patients at risk and to flag that risk. That occurred in March 2018.
In relation to the Chronic Pain Management Team a referral process is conducted, and the team will review the patient on the Ward and that is working well.
In relation to the CCTV in the TCH foyer and the recommendation in relation to it that the visual feed include balcony on level III RN Gallagher indicated that recommendation was not implemented. RN Gallagher indicated that the MAPU team was not consulted on that result and her personal view was that they should have been.
RN Gallagher was unaware of any change in the process of notification of the death to Police nor of the cleaning of the death scene preservation of evidence.
RN Gallagher was aware that TCH had an accreditation survey in March 2018 and that as a consequence of that accreditation survey there were a number of health standards found not to of been met and that survey also identified two extreme risks in relation to patients at risk, and one of those risks alluded to was the death of Ms Douch.
In March 2018 RN Gallagher had a role in the accreditation survey. She was responsible for ensuring the hospital standards were at the national standard for accreditation. RN Gallagher accepted that patients in the MAPU include patients at risk.
This included her assessment of the ward response to at risk patients. It included her giving consideration to the events of Ms Douch’s death. RN Gallagher indicated that prior to her returning to her position some parts of the process of reviewing clinical handover and the multidisciplinary team meeting were underway. She accepted that in March 2018 the not met report was released and there were findings of extreme risk in relation to at risk patients.
RN Gallagher indicated that from that point it was confirmed that they needed to continue changes and ingrain them into the team environment. RN Gallagher stated they did nothing more than what they were doing in response to the CRC recommendations. It was her view that they were doing something different with the new processes and that’s why they continued with them.
RN Gallagher agreed that in light of the accreditation survey report that they were conscious of those recommendations and continued to work on the CRC recommendations to improve the care for patients.
RN Gallagher stated that team nursing is now implemented, and it is a much more effective way of caring for patients and supporting staff. Ms Douch’s death also raised issues in relation to how staff work on the shift and that led to the team nursing.
RN Gallagher was asked about RN Karia’s conduct in relation to the conversation she had with Ms Douch, which including the notes she made in the handover details about that conversation. RN Gallagher said she had no concerns as she knew her well and expect she would do exactly as she judged appropriate.
RN Gallagher indicated that there is now a process whereby all observations are recorded electronically on a laptop on the observation trolley. This practice commenced in March 2018. RN Gallagher stated that she can log onto the computer and review all the patient’s observations and look at trends in relation to whether a patient is becoming unwell.
In terms of the policy ‘When a Death Occurs’, RN Gallagher said she is familiar with, particularly the nursing side of what is to be done when a patient dies. She is aware that it was reviewed in 2017 although she was not consulted about it. It was her view that she should have been consulted as should all CNCs.
In relation to Dr Swaminathan’s suggestion for a fully integrated electronic note system, RN Gallagher thought that would be a wonderful thing. That suggestion is in the process of being undertaken. RN Gallagher also approved of the better communication and coordination within the multidisciplinary teams.
In relation to increasing’s resources, RN Gallagher suggested that something which is pertinent to her work and she has a process of escalating that issue. In terms of locking the ward down RN Gallagher disagreed with that suggestion, given 80% of the patients are unwell medical patients and there is an ongoing stream of family and medical staff coming on to the wards. RN Gallagher indicated there is no need for a chronic pain consultant on the ward as there is more collaborative approach with the medical side for that.
Professor Matthew Large
Professor Large is a Conjoint Professor of psychiatry at the University of New South Wales, and the Clinical Director of the Mental Health Services Prince of Wales Hospital
Professor Large provided a report in relation to the four deaths that are the subject of this inquest. That was exhibited as CD 15 phase 2
The principal features of his work and research area is the mitigation or management of suicide risk in psychiatric inpatient units. Professor Large has written a number of articles which have been published in medical peer review journals.
Professor Large has given evidence in respect to approximately 30 matters involving inpatient deaths of this nature. Almost all of them have been by hanging.
Professor Large has participated in international research in respect of a goal of zero suicide in inpatient facilities which is driven by a number of researchers who are encouraging health services to formally adopt the goal.
Professor Large visited the AMHU in July 2018. It was his view that it was a large, clean, and quiet facility on the day he attended. He thought the ward was an unusual design and stated that he had not seen one like it. In his view it was a very large area which
stands in contrast to ward sizes that are now generally becoming smaller. There was also the concern in respect to the steps travelled by the nursing staff, which were raised as some logistical issues. However, he was impressed by its amenity, particular for the patients. Professor Large suggested that it compares very well with international facilities, and indeed the space was important to prevent or lessen violence between patients and RNs, or between patients.
Professor Large opined, in respect of ligature minimisation measures, that he is aware of only one area that has a trial of the door pressure sensor, other than Waypoint in Ontario. Professor Large opined that in terms the application of pressure sensors, facilities use them, and they should have done so at least five years ago when they first became available.
Professor Large placed a caveat in that where alarms and monitors are used. there is a potential that the patients will get less attention because more reliance is placed on the alarms, particularly when they do not work. It was his view that after calculating the average number of deaths of inpatients, the installation of the sensors might prevent one death from suicide in every 40 years.51
In relation to the pulse oximeters, Professor Large was well aware of the use of them and thought it was a good idea. A caveat placed upon it was the possibility of false positives and patients removing the monitors.
Professor Large opined that there is a perception that too much emphasis is placed on checking people to see if they are alive, rather than checking them to see if they are okay. Professor Large gave an example that in New South Wales the policy is now known as observation and engagement policy.
Professor Large was reticent to say that these measures were a panacea, and suggested suicide in inpatient facilities is a complex problem and no simple solution can fix that. However, it is a tool in the toolbox that can be used.
In relation to whether ensuites should have doors, Professor Large was not in favour of them. However, others have indicated that they give amenity and privacy and that is more important than ligature risk.
The photographs shown to Professor Large show the door handle used in the facility and he understood them to be anti- ligature design. In answer to a question from me about the method use by at least one of the deceased, Professor Large was aware that there was at least one person had used the door handle as a ligature point, but in his view it was uncommon. The most common method was to jam a sheet or an item of clothing with a knot in it between the top of the door and the doorframe. Professor Large agreed with my suggestion that a door handle that was flush with the door (recessed handle) would be an improvement and agreed that it should be done.52
The type of door that was shown to Professor Large, was, in his opinion, installed in many units and have been so for many years. They were recognised to be anti-ligature because of the downward slope.
Professor Large indicated that in New South Wales there are psychiatric units attached to emergency departments call assessment units. They are short stay units and are 51 Transcript of proceedings dated 7 September 2018 (p 352 – 353).
52 Transcript of proceedings dated 7 September 2018 (p 356).
designed so that patients with mental health issues do not go into the emergency department. The patients are able to stay for up to 72 hours or longer, if there are no beds in the acute mental health unit or the patients are so vulnerable, they should be placed in an acute unit.
Professor Large indicated that bed block is a significant problem in emergency departments and hospitals, indeed the number of presentations has doubled in under a decade. Professor Large indicated that it is not uncommon to turn up to work on a Monday morning and five or six people in the emergency department present with a primary mental health care problem. He said it’s more common than asthma or chest pain.
In respect to searching patients, particularly with the knowledge that Ms Fisher used a cord from her dressing gown as a ligature, Professor Large said that in NSW the Mental Health Act allows for searches. Those searches are an ordinary search, and a frisk search, and voluntary patients can of course consent as a condition of them being admitted to the hospital.
Professor Large indicated that belongings are searched to remove belts, and dressing gown, and shoelaces, and now telephone charging cables, are removed as well.
Professor Large indicated that bed sheets are the most common ligature used at the present time.
Professor Large indicated that there are various levels of observations, from a one-onone special observation, to a much lesser observation schedule. Importantly he indicated that the one-on-one special observation is not associated with lower levels of suicide and self-harm in hospital. However, there is evidence that hospitals that have some observation policies have fewer episodes of self-harm, and there is evidence that some suicides are interrupted by observation levels.53
Professor Large opined that there is a widespread perception that the observation levels have not worked well because they cannot discriminate between low and highrisk patients. As half of all suicides occur amongst people perceived as low risk and the aim is to have no suicides, picking up half of the cases is not good enough. Essentially, Professor Large indicated that conflating risk and observation is a problem. Observation level should include what the patient needs rather than what they might do in the future.54
Professor Large accepted that this was a vexed area and he had been critical, academically, of risk categorisation and his view is now widely accepted. Professor Large accepted that suicide risk cannot be removed entirely, and the RNs observe it more as a predictive risk. Ultimately, there was a perception that there was too much checking whether people were alive, rather than checking on whether they were okay.
Professor Large indicated that at the Prince of Wales there is no designated medical psychiatric unit and patients go into a medical ward. It was his opinion it was not helpful to have locked wards because patients in hospitals have freedom of movement.
53 Transcript of proceedings dated 7 September 2018 (p 361) 54 Transcript of proceedings dated 7 September 2018 (p 362).
In cross-examination, Professor Large opined that he would be very happy to swap his psychiatric unit at the Prince of Wales for the one in Canberra because of its modern outlook, its openness, and cleanliness. He accepted that the design of the wings does pose some difficulties in respect of geography and direct observation but that could be overcome, Professor Large said it is a balancing of benefits for the patient against design issues. It was his view that AMHU was not a unit which would have more suicides in the future, in fact in his view it would probably have less.
Professor Large indicated that there is a high suicide rate in psychiatric hospitals in a study conducted after 2001,1 in 600 admissions ended in suicide. On a per bed bases its 50 to 60 times that of the general community. It is clear that modifications will need to be done to prevent further suicides. However, there is a balancing act so that is more homely rather than feeling like a jail. It was his view that the Canberra ward actually conveyed some sense of optimism, which can be beneficial for the patients.
It was Professor Large’s opinion that removing the ordinary door furniture and replacing with the anti-ligature door furniture after Mr Bearham’s death was sensible. In relation to Ms Fisher’s death, it was more about her belongings rather than the ligature points.
Further, he said whilst it is important to make wards safe, exactly when that should be done in a particular unit depends on other factors.
He suggested that he would win that war and that the ensuites would not have doors on them. Further, Professor Large said that the units would move away from the ligature point door furniture to something different.
Professor Large said that one third of the registered inpatient deaths are by hanging, therefore it is an extremely important issue. However, he also indicated that the argument for ensuite doors is due to privacy and the argument for doors on bedrooms is to do with safety and privacy. These are also important considerations. It is also important to have, what he terms, interpersonal treatment aspects that are sufficiently protective. However, he was also of the view that that is very difficult to achieve.
Professor Large also indicated that unit size is an important factor, although that has implications in relation to costings for staff and the like. It was his opinion that approximate 20 people per unit is a suitable number, when it gets above that it can be problematic.
Finding appropriately qualified staff is a difficulty which all facilities endure. Those difficulties arise from not having RNs qualified in psychiatric nursing, a high turnover of staff and RN shortages. Professor Large indicated that often after traumatic event in psychiatric unit, one of the casualties is the nursing staff. There is also a correlation between violence, being assaulted, and staff leaving that service of the profession.
Professor Large agreed that it is important to consider the management of safety of the patient and prevention of suicide. It is also about the patient feeling comfortable and knowing that someone is there to help them. Professor Large agreed, when I indicated that patients are often at a point in their life where they do not accept counselling, and the like and it would take some time to get to that point.
Professor Large opined that the rate of hospital suicide is very high, but it is astronomically high in the immediate discharge timeframe.
After considering the renovations and the non-ligature point rooms now being remediated, it was his view that The Canberra Hospital move from being toward the front of the pack to definitely being at the front of the pack, in terms of hospital amenity and safety.
Professor Large opined that despite the renovations being expensive and complicated, it seemed to him that retrospectively it should have occurred a year or two earlier.
However, that is difficult with older units halfway through their lifespan, where more money is not keenly spent on renovation given there is the possibility of new unit being considered. Administrators are particularly unhappy to consider money being spent on older units for that reason.
Professor Large agreed that the new ligature risk management procedure, adopted and developed by TCH, is a very sensible document.
Professor Large indicated that in the period between 2008 and Mr Bearham’s death there have been two deaths by suicide from hanging. There were changes made from the first death where they put ‘cat and kitchen doors’ in. However, Professor Large he wasn’t sure about whether any changes occurred following the second. Professor Large indicated that RNs are meant to do an environmental check every shift. However, he thought that they should do the checks a bit more often than that.
In relation to the ‘ligature risk management for mental health’, it was his opinion that it was a very good document.
In relation to handovers and multidisciplinary care meetings, Professor Large indicated that the National Confidential Enquiry found that proper multidisciplinary team meetings are associated with lower rates of suicide. The handover should also be in person with some degree of personal communication. It was his view that the ISBAR way of handing over is a good way to do it.
Professor Large indicated that there are three types of handovers; clinical handover from Consultant psychiatrist, and one with the registrar, nursing staff, and shift staff , as well as the nursing shift to shift. Those meetings need to be structured communications about the salient aspects of patient care and safety.
Professor Large indicated that, where you have a large number of patients, including recently in his own unit, he has broken the handover down to separate meetings to accommodate the number of patients. Professor Large indicated that team nursing is a direction that his unit is going in.
In relation to the prefilling of observation times of patients, as was the case in Mr Bearham’s death, Professor Large indicated that in his experience people pre-fill and backfill and sometimes do not check in those timeframes at all. This should not be done in his view. However, despite his view that randomised observations may not work either, because a phenomenon of patients harming themselves just after their observations, it may be an element of randomness was appropriate.
In respect to clinical assessment of patients, Professor Large gave some history relating to this issue. It was his view that risk assessment is about what the patient is actually doing, saying, and thinking, rather than a probabilistic analysis of what they might do in the future.
It was his view that a patient coming in needs to be assessed on days 1, 2 and 3, as well as seeing a clinician regularly rather than “pontificating about what the patient might do”.55
Professor Large indicated this is a complex area, and risk assessment as a tool is widespread. Although it is not particularly supported scientifically there is a question is what do you replace it with. It was his view that the form used by ACT Health was a good form. Having said that, it was his view that if you are a mental health patient in a psychiatric ward you have a foreseeable risk of suicide. The assessment when carried out does not necessarily reflect the level of risk, because all patients are found at high risk.56
Professor Large agreed that the reliance on the expression of suicide ideation is not a very sensitive indicator of suicide. The risk assessment could be predictive and then if it’s a low prediction one may not be as vigilant as one ought to be and the problem is it gives you a false reassurance.
Professor Large indicated that “Ken, Nicola, Anthony, and Christine” were by any measure high risk patients.57 Professor Large agreed that mitigating against that risk by taking away risk factors such as ligature points is a starting point.
Professor Large was asked a question in relation to a person’s right to property, versus the capacity of the unit in searching people and property, particularly under the Human Rights Act in the ACT. Professor Large opined that presumably a voluntary patient wants to be in hospital and the desire to be in hospital can be used to leverage and search them. That’s what they do at the Prince of Wales Hospital. It is a set of conditions for leave. It involves an understanding by the patient and if they leave the hospital then the hospital has a right to search them if they are concerned that they might bring contraband onto the ward.
When a patient is held involuntarily, they can get some form of agreement but can search the patient if they don’t agree. That is limited however, to a frisk search and a property search. Professor Large indicated they have more power over visitors and if they consider a drug dealer is coming in, they can exclude them.
In relation to the situation relating to Ms Fisher where she had the belt tie belonging the bath robe on her in the ward, Professor Large opined that if the patient was involuntary, staff would indicate that the belt would pose a risk to them and remove it. If the patient was voluntary it may be trickier. However, if a patient is suicidal and does not want to give you a belt, then you have to think about whether they should be held as an involuntary patient.
In terms of implementing particular processes, such as checklists, it’s important to educate staff so they can make sensible judgements about things and document why they are doing it.
In terms of education, it was Professor Large’s opinion that a designated RN educator with weekly teaching programs and accreditation for various procedures, is important.
This is particularly the case in relation to new graduates.
55 Transcript of proceedings dated 7 September 2018 (p 393).
56 Transcript of proceedings dated 7 September 2018 (p 395).
57 Transcript of proceedings dated 7 September 2018 (p 396).
In terms of recommendations, Professor Large opined that it is important to have an educated, caring, recovery focused, body of nursing and medical staff rather than just the physical environment. Including facilities where staff are well-trained and can exercise their professional judgement in a relatively horizontal structure. For example, a junior RN can speak to a psychiatrist about a patient. It is about paying attention to human resources as they are the biggest cost in psychiatry and where you get ‘bang for your buck’.58
In relation to CCTV monitoring, Professor Large opined that having patients monitored in the bedroom creates privacy issues and can separate patients from staff who just monitor them. However, in public areas it was his view it was not such a bad idea because monitoring allows you to work out what happened. Professor Large was more hesitant in monitoring being used to ensure patient safety.
In relation to a question relating to Mr Lucas and prior suicide attempts, Professor Large indicated that past suicidal attempts particularly a serious one is probably the single strongest kind of long-term predictor of suicide.59
In terms of observations, Professor Large was aware that Mr Lucas’s treating psychiatrist opined that had there been 15-minute observations available he would have been placed him on those. However, as the half-hour was the only option he changed the observation to that option from hourly observations. That change was not recorded, and Mr Lucas remained on hourly observations.
Professor Large said that the risk category does not directly flow in relation to the observation category. Professor Large said that it is important to find out what is going on with the patient, rather than just checking on him or her. Professor Large agreed that if Mr Lucas had been on 15-minute observations the opportunity to hang himself would have reduced.
58 Transcript of proceedings dated 5 September 2018 (p 399 – 400).
59 Transcript of proceedings dated 7 September 2018 (p 401) [my emphasis].
Summary of Submissions Counsel Assisting the Coroner Jurisdiction
Counsel Assisting the Coroner submitted that the jurisdiction in respect of each death arises under section 13(1) of the Coroners Act 1997 (‘the Act’). In respect of Mr Bearham and Ms Fisher, the jurisdiction stems from section 13(1)(c), which requires a Coroner to hold an inquest into the manner and cause of death of a person who dies, or is suspected to have died, a sudden death the cause of which is unknown. In respect of Ms Douch and Mr Lucas, the jurisdiction arises under section 13(1)(a), which requires a Coroner to hold an inquest into the manner and cause of death of a person who dies violently, or unnaturally, in unknown circumstances.
They further submitted that the scope of enquiry available to a Coroner is set out in the decision of Onuma v The Coroner’s Court of South Australia [2001] ASC 218.
Required Findings (p.4) Counsel Assisting the Coroner submitted that, as per subsection 52(1) of the Act, a Coroner must find, where possible: the identity of the deceased; when and where the death happened; and the manner and cause of the death. These findings must be recorded in writing, as per subsection 52(3) of the Act. Subsection 52(4) of the Act stipulates that the Coroner’s findings must state whether a matter of public safety is found to arise in connection with the inquest or inquiry and must comment on such matters where they do arise. The findings may comment on any matter about the administration of justice connected with the inquest or inquiry. Subsection 55(1) of the Act outlines the requirements to notify a person against whom adverse comments may be made, and to allow that person an opportunity to respond. Counsel submits that the Briginshaw v Briginshaw (1938) 60 CLR 336 principles are particularly relevant in considering and /or making adverse findings.
Counsel referred to a number of cases that provide guidance on the role of the Coroner: Briginshaw v Briginshaw (1938) 60 CLR 336, 361-2 (Dixon J); R v Doogan; Ex Parte Lucas Smith & Ors [2005] ACTSC 74 (5 August 2005) [12] (Higgins CJ, Crispin and Bennett JJ); Harmsworth v The State Coroner [1989] VR 989, 997 (Nathan J).
Section 55 (p. 5) As provided by s 55(1) of the Act, an adverse comment against a person may not be included in a finding or report made under this Act unless that person has been provided with notice of that comment, and an opportunity to respond to the comment.
In considering and/or making adverse findings, the Briginshaw principles apply.
Counsel Assisting the Coroner noted that interim findings had been made at the close of factual evidence as to the cause of each person’s death.
I note that Pages 5-23 outline detailed findings of fact. I do not propose to summarise those matters and I have attached as annexures all Counsel submissions.
Counsel Assisting the Inquest – Summary of Factual Matters Requiring Resolution (pp 23-31) ‘At Risk Category’ Observations/Time of Death (Fisher) (p. 23)
The correctness of records of observations taken and statements said to have been made by treating staff of Ms Fisher on the day she died, and whether it was possible to determine the precise time of her death, were live issues in the inquest. Specifically, the coronial investigator held concerns about the ARC check said to have been conducted at 9.15am by Nurse Matsika on 20 March 2015.
Nurse Robson and Dr Wood gave evidence regarding observations of Ms Fisher on the morning of 20 March 2015. Counsel Assisting the Coroner submitted that both Nurse Robson and Dr Wood were truthful witnesses whose evidence should be accepted.
Dr Cole was called to the AMHU by the ‘code blue’ and was the emergency specialist who attempted to resuscitate Ms Fisher. He spoke with Police on 20 March 205; provided a statement shortly before hearing; and provided evidence in court. Counsel Assisting the Coroner submitted that Dr Cole was an argumentative and defensive witness when giving evidence at the hearing, and there were a number of discrepancies between his statement, oral evidence given in court and the transcript of his conversation with Police. Counsel submitted that, to the extent that there were such discrepancies, the version of events described in Dr Cole’s conversation with Police on 20 March 2015 and/or his contemporaneous clinical note should be preferred. Given the application of the Briginshaw principle, Counsel submitted that the evidence does not rise to a level that would properly support an adverse comment or finding against Dr Cole. I agree with that submission.
As to the conflicting evidence provided by Dr Cole in relation to who last saw Ms Fisher alive prior to her death, Counsel submitted that the Coroner should find on the balance of probabilities that Dr Cole was told by Nurse Matsika during the process of attempted resuscitation that the last sighting of Ms Fisher was at 9am.
Counsel Assisting the Coroner outlined some inconsistencies between the evidence provided by Nurse Matsika and other witnesses. Counsel submitted that the preponderance of evidence, considering the Briginshaw standard, is such that the Coroner may be comfortably satisfied that the check supposedly undertaken by Nurse Matsika at 9.15am on 20 March 2015 did not take place.
Counsel further submitted that there are significant consequences that follow from a finding that the 9.15am check did not take place, including that Nurse Matsika had made a false and misleading statement on the ARC chart; has given evidence that is false and misleading in a material particular both in his statement and in oral testimony; and may have attempted to pervert the course of justice. The Coroner, therefore, may be required by virtue of s 58 of the Act to refer this matter to the DPP for consideration of prosecution action. It was, however, submitted that any referral would not engage subsection 58(3)(b) of the Act. [I do not agree with that submission in its entirety and my view on the matter is reflected in my considerations below.] Effect of Belimumab BCT (Douch)
Counsel Assisting the Coroner noted that a question arose as to what, if any, role Ms Douch’s enrolment in the BCT may have had in her death, by virtue of a potential side effect of Belimumab use said to be suicide. Based on the evidence of Professor Cook,
and the expert academic papers supporting his evidence, Counsel submitted that the Coroner should find, as a matter of fact, that Ms Douch’s possible prior ingestion of Belimumab had no effect or causal connection to her death.
Matters Going to the Administration of Justice (p. 32)
Reporting of Likely Deaths to the Coroner (p. 32)
An issue for consideration in this case is the manner in which significant incidents of self-harm are reported to the Police. At the time of the deaths of Mr Bearham, Ms Fisher, Ms Douch and Mr Lucas, there was no distinct policy for the notification of Police in relation to potentially fatal ‘critical incidents’ or acts of self-harm likely to lead to death [158].
There was a failure to maintain evidence in relation to the death of Mr Bearham.
Counsel Assisting the Coroner submitted that the evidence given by staff at the AMHU at the time of Mr Bearham’s death clearly indicated the lack of a coordinated response to the incident in which the preservation of the scene was given priority [160]. The most likely explanation for the failure to properly respect the scene and maintain evidence was that given Mr Bearham’s suicide attempt was not immediately successful, no thought was given to the evidentiary requirements of a coronial investigation. Counsel Assisting the Coroner, however, submitted that, shortly after his transfer to ICU, Mr Bearham’s poor prognosis was evident, and from that point there was no reason Police could not have been notified of his likely impending death [161]. While in this case there was sufficient information for the Coroner to make a finding as to the manner and cause of Mr Bearham’s death, the missing evidence could have provided relevant facts had TCH acted more proactively in managing the scene [163]. Counsel Assisting the Coroner did not regard the failure to preserve evidence as malicious but submitted that it represented a systemic failure on the part of TCH [164].
Response when Death Reported to Coroner (p. 34)
A further issue arose in relation to the provision of statements and to investigators following the four deaths. Ms Hemming sent an email to relevant staff outlining their option to provide a statement or interview with Police; however, a number of witnesses in the Bearham and Lucas matters gave evidence that they would have spoken directly to Police had they been given the opportunity [177]. Counsel submitted that: “While it is not contested that staff were sent an email by Ms Hemming, it is clear from their evidence that some did not receive it or read the email in a timely fashion, or they did not understand it was an option to speak directly with Police” [177].
Both S/C Norman and D/S/C Best gave evidence regarding the issues caused by the provision of, often delayed, written statements as opposed to conducting interviews with staff in a timely manner. Counsel submitted that: “The practical effect on the hearing for these inquests was that many witnesses were simply unable to recall in significant detail key events in the timeline of the deaths and responses due to the passage of time and a failure to make a statement or make comprehensive notes contemporaneously with the incident” [181].
There was no recommendation of an adverse comment or finding, but it was submitted that the policy document ‘When Death Occurs’ in place at the time clearly did not adequately balance considerations of staff welfare with the need to facilitate the course of justice [183].
A new policy is now in place in relation to this issue; however, Counsel submitted that the new version still creates a risk that staff may feel inadvertently pressured to take a course of not speaking with Police [184]. Counsel Assisting the Coroner submitted that the Coroner should recommend changes to the TCH Operational Procedure ‘When Death Occurs’ to include a more detailed outline of the options available to staff when involved in a coronial matter. The changes should place greater emphasis on the capacity of staff to participate in a ROC with a Police officer and should encourage participation in such processes. [185] Further, Counsel submitted that the policy should expressly authorise the timely provision to Police of the names and contact details of all relevant staff, as well as formalise the procedure for internal communications to staff in relation to coronal investigations [185].
Possible Matters of Public Safety (p. 39) Searches/Appropriateness of Patients’ Personal Items (Bearham, Fisher, Lucas) (p. 39)
Counsel Assisting the Coroner submitted that a matter of public safety arose in the Bearham, Fisher and Lucas matter in relation to those patients bringing onto the respective wards items that they should not have had in their possession while receiving inpatient treatment [188]:
Mr Bearham’s toxicology results after his attempt at suicide returned a positive result for methamphetamine at a level which indicated it must have been consumed at a point at which Mr Bearham was an inpatient at TCH [189];
Ms Fisher was admitted wearing a dressing gown and used the belt of that dressing gown to complete suicide [190]; and
A search of Mr Lucas’s room after his death revealed bottles of alcohol hidden under his mattress [192].
In relation to Ms Fisher, all of her key treating professionals gave evidence at the hearing that they did not see the belt and that, if they had seen it, they would have taken action in respect of the belt [190]. Similarly, if the alcohol had been found with Mr Lucas, it would have been removed [102(b)].
AMHU Operational Procedure at the time included guidance for the searching of consumer’s person or property [193]. Counsel submitted that those policies “were patently inadequate to properly protect patients from items that could be used for harm.
The policy had excessive and inappropriate adherence to patient privacy” [193].
Further, it was submitted that the training provided to staff on the relevant policies was inadequate [194]. In relation to Ms Fisher, Counsel accepted the evidence of the individual staff that they did not pay attention to the belt; however, notes that the fact that Ms Fisher was on the ward for three days, was seen by a number of treating professionals, and no one ‘saw’ the belt is “a shocking indictment of the system” [194].
Assessment of Suicidality and Clinical Risk Assessment (all matters) (p. 42)
The submissions in relation to this issue were prefaced with the observation that assessment of suicidality is largely a clinical judgment dependent on the facts of each case. Per the evidence of Professor Large, there is no evidence-based mechanism with any degree of sophistication which accurately predicts suicidal risk [198]. Nevertheless, Counsel Assisting the Coroner submitted that issues arose in relation to each of the deaths as to the adequacy of the assessments of suicidal risk given, they all ultimately committed suicide.[199] At [200] sets out the process of assessing suicidality upon admission to the MHAU or AMHU.
The evidence in the matters indicates that while the appropriate assessment was used by clinicians on admission of each patient, there was, at times, a lack of relevant information available to those staff that may have impacted the score given to the patient [202].
Issues also arose in relation to the frequency of reassessment. Counsel submitted that the system’s failure to reassess Ms Fisher for suicidality in a comprehensive way was a material matter which contributed to her death [205]. It was noted, however, that this matter was resolved rapidly after Ms Fisher’s death by virtue of a directive that patients were to be reviewed at least every 24 hours [205].
In relation to Mr Lucas, the failure to communicate his altered risk category provided him with a greater opportunity to hang himself. [207] Due to changes in policy regarding communication of reassessment of risk category since Mr Lucas’ death, it was submitted that no further recommendations are warranted [208].
Counsel Assisting the Coroner submitted that recent developments in technology could be used to facilitate the process of taking observations, for example, increased utilisation of CCTV monitoring for welfare checks and the use of pulse oximeters. It was
submitted that the Coroner may wish to recommend that ACT Health give express consideration to these matters [211].
In submissions, Counsel Assisting the Coroner gave some consideration to non-clinical factors that may have a bearing on suicidality, such as pressures to discharge patients and pressure regarding bed numbers [214]. It was submitted that, while it would not be appropriate for the Coroner to make a specific recommendation as to a particular amount of funding, the Coroner may care to make observations about issues such as lack of funding and under-resourcing of hospitals, particularly in relation to the mental health sector [216].
Given the ongoing regard to improving observation processes and reducing the risk of suicide, it was submitted that, while there is room for improvement in TCH’s approach to the assessment of suicidality, no matter of public safety arises in relation to this topic [218].
‘Queue jumping’ for admission to AMHU (Fisher) (p. 47)
The New MHSSU Model of Care (Fisher) (p. 49)
Handover and Procedures for Transfer of Information (all matters) (p. 50)
In relation to issues raised regarding handover procedure, Counsel Assisting the Coroner submitted that, although there were major shortfalls with the manner in which handover was managed at the time of these deaths, it cannot be said as a general proposition that inadequate handovers were the direct cause of any person’s death [237]. TCH has now revised its handover practices as set out in the AMHU Operational Procedure; therefore, it was submitted that no further recommendation is warranted in respect of this issue [238]. In relation to Ms Douch, the MAPU handover process has been revised since her death [239].
Another issue raised in submissions was the lack of access or attention given to records arising from a different part of the hospital [240]. The lack of access or timely access to MHAGIC records in relation to Ms Douch and Ms Fisher does not appear to have had a material bearing on any of the patient’s deaths; therefore, it was submitted that no adverse finding is warranted [241].
It was submitted, however, that the Coroner may wish to reinforce the need for collaboration between different medical specialities and different treating areas [243].
Failure of Activation of Code Black (Bearham) (p. 53)
Response to Ligature Risk (Bearham, Fisher, Lucas) (p. 54)
Counsel Assisting the Coroner stated that: “Although it is perhaps not fair to say that ACT Health did nothing in response to then Chief Coroner Cahill’s recommendations, or in the immediate aftermath of any of the deaths presently under examination, it is submitted that the response by ACT Health to the issues of ligature risk at all relevant times was inadequate and belated [251]. Five pieces of evidence are relied upon to support this submission; they are outlined in [251]. Two of the most important points are that (1) the ACHS NSQHS Standards Survey for the TCH accreditation process in March 2018 identified the risk to at-risk patients as ‘extreme’; and (2) the specific manner of death by hanging by ligature and/or by use of a door or door handle had been highlighted by then Chief Coroner Cahill in 2004, yet continued to occur [251(d) and (e)]. Counsel does not suggest an adverse comment or finding against a particular person, but instead submit that this inquest has uncovered a systemic failure over many years on the part of ACT Health [252].
New measures intended to be adopted in the AMHU go a long way to address issues of ligature risk; therefore, it was submitted that there is no need for any recommendations in respect of the specific matter of ligature risk [254]. However, Counsel submitted that, given the lack of regard to previous Coroners’ recommendations, the Coroner may wish to consider making a formal recommendation that ACT Health formalise an accountability and governance process to ensure that critical incidents are properly investigated, and any recommendations are considered and implemented [255]. Counsel note that the Australian Council on Healthcare Standards accreditation review of ACT Health came to a similar conclusion, recommending an independent mental health advisory body oversee the implementation of its recommendations [256].
Training of MHJHADS Staff (all matters) (p. 58)
Possible Recommendations (p. 59)
In light of this, Counsel stated that many recommendations which may have been expected are no longer necessary [259].
Page 60 contains a summary of suggested recommendations (also found in the table below).
F/C Gordon, the coronial investigator in the Douch matter, also suggested the following recommendations [261]:
Patients at risk of self-harm should have a separate form completed on admission
ACT Health should implement the mitigation strategies identified in its falls risk assessment
Webster packs should be mandatory for patients who receive regular prescriptions for strong opioid medications
The witnesses called also put forward the following additional recommendations [262]: a) More staff on the wards – Nurse Schmidt, Dr Harvey-Smith, Dr Rodrigo, Nurse Shepard, Dr Swaminathan, Nurse Golding, Nurse Nkomo b) Specialist mental health staff to be utilised in mental health wards – Dr Grey, Nurse Golding c) Better designed and smaller wards – Dr Ahlin d) MAPU to have a lockdown facility – Nurse Shepard e) A fully integrated electronic notes system – Dr Swaminathan f) A chronic pain consultation service for TCH – Dr Swaminathan g) More multidisciplinary team meetings and better communication between treating teams – Dr Swaminathan h) Move away from verbal handovers – Nurse Elderidge Possible Section 55 Notices (p. 62)
[263] notes the adverse comments or findings that are put forward in relation to the Territory.
[264] outlines the adverse comments or findings that are put forward in relation to Nurse Matsika (covered in [129]-[147]).
Summary of submissions for the ACT Contents
• Summary of events [1]-[9]
• Factual matters requiring resolution [11]-[122] o “ARC” observation – Time of Death (Ms Fisher) [12]-[121] o Effect of Belimumab (Ms Douch) [122]
• Matters that are said to go to the administration of justice [123]-[152] o Reporting of likely deaths to the Coroner [123]-[136] o Response when death reported to Coroner [137]-[152]
• Possible matters of public safety [153]-[242] o Searches – Appropriateness of Patient’s Personal Items (Bearham, Fisher, Lucas) [154]-[178] o Assessment of Suicidality and Clinical Risk Assessment (all matters) [179]- [212] o ‘Queue jumping’ for admission to the AMHU (Fisher) [213]-216] o The new MHSSU Model of Care (Fisher) [217] o Handover and Procedures for Transfer of Information [218]-[223] o Failure of activation of Code Black (Bearham) [224] o Response to Ligature Risk (Bearham, Fisher, Lucas) [225]-[238] o Training f MHJHADS Staff (all matters) [239]-[242]
• Possible recommendations [243]-[292]
• Possible section 55 notices [293]-[301]
• Concluding comments [302] Factual Matters Requiring Resolution “ARC” Observation – Time of Death (Ms Fisher) (p. 3)
In [11]-[73], the Territory sets out the evidence in relation to Nurse Matsika’s alleged 9.15am check on Ms Fisher.
Counsel for the Territory notes that: “The conduct alleged here is very serious … The proposed adverse comments would give rise to the harshest personal opprobrium. Only the clearest and most cogent evidence, approaching the criminal standard of proof, could justify the proposed findings” [77]. They submit that the evidence does not rise anywhere near a level that would allow the proposed findings to be made for the following reasons:
It is implausible that Nurse Matsika would go to the lengths of creating a false record in the ARC observation chart to make it appear as though Ms Fisher was seen every half an hour when he was not the individual responsible for that task [82]
Prima facie, the ARC observation chart did not need an entry at 9:15am to ensure compliance with the MHAU observation policy [83]
Nurse Matsika explained that he performed the check because he was worried about Ms Fisher’s physical state [84]
There is no proper basis for rejecting his explanation for the check he performed on Ms Fisher at 9.15am [85]
Dr Cole’s evidence about what he was told by other staff members does not provide a basis for rejecting Nurse Matsika’s evidence [89], because: a. It is no more than hearsay [90] b. There was other hearsay evidence that was inconsistent with Dr Cole’s information [91] c. Dr Cole’s own evidence casts doubt upon the reliability of what he was told and he was given differing answers by staff members who were visibly upset [94] d. Dr Cole’s understanding that Ms Fisher had last been seen by Nurse Matsika at 9am is inconsistent from the version of events that must follow from the proposed findings of fact [98] e. It is far more likely that the information Dr Cole gave Police was partially correct in that Nurse Matsika had been the last to see Ms Fisher, but it was at 9.15am and not 9am [99]
The reliance on the evidence of Dr Cole that Ms Fisher was ‘centrally and peripherally cold’ when she was found ignores the unchallenged evidence of Professor Ranson [101] a. The evidence from Professor Ranson was that it is not possible to conclude whether the ligature was applied before or after 9.15am [101] b. Dr Cole was clear that he would defer to a forensic pathologist as to what his observations may mean in relation to the time of death [110]
The summary of S/C Jevtovic’s findings is not necessarily inconsistent with Nurse Matsika’s evidence, as there is some uncertainty over which record she was referring to when she stated that the last recorded ‘interaction’ with Ms Fisher was at 8.40am [111]-[112]
In conclusion, Counsel for the Territory submitted that “there are no doubt inconsistencies between the evidence given by RN Matsika and other witnesses on certain details of the events of 20 March”, but that “There are similar inconsistencies in the evidence given by other witnesses. This is unremarkable and indeed to be expected” [120].
Further, they state that: “What is not present is clear and cogent evidence, or for that matter, any reasonable evidential base, for making the very serious adverse findings against RN Matsika that have been put forward for consideration by Counsel Assisting” [121].
Effect of Belimumab (Ms Douch) (p. 18)
Matters Going to the Administration of Justice Reporting of Likely Deaths to the Coroner (p. 19)
At the time of Mr Bearham’s attempted suicide, there was no policy or operating procedure that required staff to notify Police after an attempt at self-harm. There was, and is, no such requirement at law [125]. The only issue is whether there should have been a policy in place in relation to the scene of an attempt at self-harm [127]; there is no evidence to support such a finding or comment [128].
The Territory submitted that Counsel Assisting’s submissions overstate the importance of this issue in relation to Mr Bearham’s death [129]. While the retention of the ligature used by Mr Bearham would have been of some use, “there were broadly consistent and reliable accounts of witnesses as to how the ligature was fixed” [129]. In relation to Ms Fisher, Dr Cole’s decision to move her was not done in ignorance of the fact that there would be an investigation [130]. Indeed, Dr Cole’s acknowledge that he was aware that it may not be preferable to move her body for forensic reasons, but ultimately, he decided to do so to preserve her dignity [130]. Again, the Territory submitted that Counsel Assisting’s submission overstate the impact of this decision on the investigation [131].
Changes in Procedure
Response When Death Reported to Coroner (p. 21)
Timing of The Provision of Statements
The reason for delay was that Ms Hemming only became aware that the Coroner might be assisted from evidence from these witnesses right before the commencement of the Inquests [145]. There was no evidence to suggest that she should have had that understanding any earlier [145]. This submission bears out my point that trained
investigators should investigate these deaths so that relevant evidence is gathered in a timely manner.
While some of the witnesses expressed an inability to remember details when giving oral testimony, this was a function of the period of time that elapsed between the hearing and the events in question, rather than anything to do with the way in which their evidence was obtained [149].
The Understanding of Witnesses That They Could Speak with Police
Further, they submitted that there is no basis for a finding that the quality of evidence of any witness referred to in [177] would have been better had they participated in an
Comments and Recommendations
Possible Matters of Public Safety Searches – Appropriateness of Patient’s Personal Items (Bearham, Fisher, Lucas) (p. 25)
These submissions address [188] to [197] of Counsel Assisting’s submissions.
The Territory accepted that, regardless of how Ms Fisher’s belt went unnoticed, it should not have happened [157]. Nevertheless, they submitted that, neither this, nor the other matters referred to in Counsel Assisting’s submissions, justifies a finding that TCH policies for searching a consumer’s person or property were “patently inadequate to properly protect patients” [157].
The Relevant Policies and Procedures
The Evidence does not Establish that the Policies were ‘Patently Inadequate’
Counsel for the Territory outlined five reasons to support their submission that the policies were not ‘patently inadequate’:
There is no evidence that Ms Fisher’s possession of a dressing gown cord was the result of inadequacy in the policies [169]
Counsel Assisting’s submissions fail to address the evidence of the training that MHJHADS staff received in relation to searching patients [170]
There is no evidence that Ms Fisher’s possession of a dressing gown cord was the result of inadequacy of training of staff [172]
All relevant witnesses stated that they would have taken action had they noticed
There is no evidence of a ‘systemic failure’ in the procedures; Dr Rodrigo had worked in the MHAU for 7 years prior to 2015 and was not aware of any other instances in which an item of risk was found on a patient [173]
In relation to Mr Lucas, written records established that there had been a discussion with him in relation to his belongings and clothing when he was admitted; there is no reference to a bottle of alcohol being brought in and no evidence that would allow a finding to be made as to how it came to be in his room [174]
The Territory accepted that the dressing gown cord and bottle of alcohol should not have been present in the AMHU. It submitted that: “These facts establish that, on these two occasions, the processes in place at the relevant time for searching the property of patients did not achieve their intended outcome… What the evidence does not establish is that there was a serious inadequacy in the search procedures applicable at the time, or in the training received by the staff” [175].
The Period After Ms Fisher’s Death
Assessment of Suicidality and Clinical Risk Assessment (All Matters) (p. 31)
Assessment of Suicidality
Since Counsel Assisting’s submission themselves note that there is no evidence-based mechanism to accurately predict suicide risk, the Territory submitted that it is necessary to do more than point to the fact there was a successful suicide attempt in order to level legitimate criticism at the process [183]. It noted that Counsel Assisting’s submissions do not identify any specific failing in any psychiatric review of any of the patients in question [184].
In relation to lack of access to relevant information, the Territory submitted that:
There is no basis for a finding that an awareness of the ED note by Dr Regner would have made a difference to the outcome of his assessment [186]; and
There is also no basis for a finding that the availability of Werribee records to Dr Ahlin or Dr Modak would have altered their assessment [187].
In relation to non-clinical factors, the Territory submitted that there is no basis at all for a finding that any non-clinical factor had any bearing on the risk assessment of any of the patients in question [190].
No Further Reassessment of Ms Fisher
Communication of Increased ARC Score (Mr Lucas) Changes to the Procedures
The Practice of Performing ARC Observations
Nevertheless, the Territory acknowledged that all MHJHADS staff will benefit from ongoing training in relation to ARC observations and accepted the recommendations at [260] (d) as being appropriate [212].
‘Queue Jumping’ For Admission to the AMHU (Fisher) (P. 36)
The New MHSSU Model of Care (Fisher) (P. 37)
Handover and Procedures for Transfer of Information (p. 37)
Changes to Procedures
Failure of Activation of Code Blue (Bearham) (p. 39)
Response to Ligature Risk (Bearham, Fisher, Lucas)
The Territory submitted that: “When the whole of the evidence is considered, it can be seen that substantial work was undertaken to minimise ligature risk well before the accreditation report in March 2018. When it was put to Ms Braun that it was not until after the accreditation process that the issue of altering doors at the AMHU received any priority, she did not accept that proposition. She did acknowledge that the accreditation reviewer’s recommendation closely correlated with the date on which funding was approved, which is true but is not such as to allow any conclusions to be drawn. She also pointed out that, at the time of accreditation, the ensuite bathroom doors were already in the process of being removed. If the remediation plan had not encountered the difficulty of creating new ligature risk, then the doors would already have been removed by the time of the accreditation report” [235].
The measures that have been taken by the MHJHADS to minimise ligature risk mean that the AMHU is one of the safest facilities in Australia in terms of ligature risk [238].
The Territory here relied on the evidence of Professor Large, who stated that he had not seen such a high level of ligature prevention in any civil hospital in NSW, the UK, or North America [238].
Training of MHJHADS Staff (all matters) (p. 45)
Changes in procedures
Proposed recommendation
POSSIBLE RECOMMENDATIONS Issues raised by CA – [260] (p. 47) Revision to the TCH’s Operational Procedure ‘When Death Occurs’ – 260
the Territory submitted that it was not reasonable for contact details of all relevant staff to be provided to Police, due to concerns about staff privacy and patient confidentiality [245]-[246].
Increased education and training on search procedures – 260
Consideration to developments in technology – 260
Training and guidance as to randomised times of observation – 260
Finalisation of the MHSSU Operational procedure – 260
Accountability and Governance – 260 Recommendations of then Chief Coroner Cahill (Inquest into the Deaths of Stefan Zywcsak, Hamish Kimlin, DS, Tamsyn Blackaby and Janice Ferguson – 2004)
[257]-[263] outlines the recommendations of Chief Coroner Cahill and the Territory’s actions in response to those recommendations.
The Territory submitted that the findings of Chief Coroner Cahill relate to a facility that no longer exists. The practices and procedures that were in place at the time of the deaths that were the subject of Chief Coroner Cahill’s findings were plainly different from those that were in place in 2015 and 2016. There is, therefore, a degree of remoteness from the circumstances of this Inquest that raises an issue as to whether there is even jurisdiction to consider whether and when those recommendations were implemented [264].
Further, the Territory submitted that, if there is jurisdiction, the suggestion that there has been a lack of regard for the recommendations of Chief Coroner Cahill is not supported by the evidence [265]. Some of the concerns that arose in connection with those deaths had been addressed by the time of hearing, and there is evidence of a process in 2007 by which each recommendation was reviewed to determine the extent to which it had been addressed [265].
Recommendations of Chief Coroner Walker (Death of Mr Galinec [2014] ACTCD 2)
[266] to [271] outline the recommendations in this inquest and the Territory’s response/implementation.
Again, the Territory submitted that the evidence does not reasonably support the comment that there was a lack of regard for the findings of Chief Coroner Walker in this inquest [272].
CRC Recommendations
The Territory submitted that, when the evidence is taken as a whole, there is no justification for the comment that there was a “lack of regard” by either MHJHADS or ACT Health for the CRC recommendations [276]. Additionally, it noted that the difficulty with the specific terms of the recommendation suggested at 260 is that there is already an accountability and governance process in place directed at the response to critical incidents [277].
The Territory accepted that consideration can always be given to improving the current system and noted that one aspect raised by Ms Braun was the time within which a CRC investigation is undertaken [278].
Recommendations raised by Witnesses – [262] (p. 55) More staff on the wards – 262
Specialist Mental Health Staff – 262
The design of the AMHU – 262
MAPU lockdown facility – 262
Move away from verbal handovers – 262
The reasons for this have been set out in their preceding submissions.
Submissions on Behalf of Dr Colin Pate
Submissions on Behalf of Sara Eldridge RN
Nurse Eldridge conceded that it was possible she had not notified a Team Leader of the changed clinical risk assessment. New procedures are now in place to ensure that similar situations do not arise again.
Submissions on Behalf of Registered Nurse Clemence Matsika
The ‘case’ against RN Matsika is based on an assumption that Dr Cole obtained information about a 0900 hrs attendance from RN Matsika himself. Only then could the record of interview amount to a prior inconsistent statement by RN Matsika as to when he last saw Ms Fisher [6]. Under examination, Dr Cole confirmed that he was not sure who had provided him the information regarding when Ms Fisher was last seen [8].
Counsel acknowledged that most of the bases for the allegations against RN Matsika are considered in the Territory’s submissions, but further reinforced the following points:
The fact that RN Matsika recorded his 0915 hrs observation of Ms Fisher on the couch is consistent with the ARC observation chart being the obvious place to keep a record of all observations, regardless of whether or not they were a part of the routine ARC checks 14
Regarding the conclusions based on Ms Fisher’s lividity, it was submitted that “the submission in subparagraph (f) is astonishing, in light of the extensive and unchallenged evidence given by Professor Ranson that such a conclusion is simply not available 14
Counsel submitted further that: “The reality was that there was no reason or motive for RN Matsika to lie about the timing, because it was not his responsibility that morning to conduct ARC routine checks at all … The irony is that if RN Matsika had not bothered to check on Ms Fisher at 09:15 and again just before 09:40, observations which were conducted outside of the ARC routine checks and only because of his concern for Ms Fisher’s welfare, he would not now be accused of forging medical records and attempting to pervert the course of justice; instead it might be RN Robson being criticised for not actually seeing Ms Fisher on his 09:00 ARC routine check and not conducting a further one before she was discovered” [17].
Reply Submissions on Behalf of Counsel Assisting the Coroner
All parties also accepted the proposed detailed findings; however, there was an error at [31]
of the submissions, whereby the ages of Ms Fisher’s children were actually between 12 and 23 years old Factual Matters Requiring Resolution (p. 2) ‘At Risk Category’ Observation/Time of Death (Fisher)
RN Matsika’s submissions say that there is no reason for him to have lied about the timing of the check. The reason is that Ms Fisher was his patient and under the MHAU procedures she was meant to be observed every 30 minutes, and this did not occur [7].
With respect, all that Professor Ranson’s evidence does is rule out a complete
pathology answer to the question of when Ms Fisher commenced suicide [8]. The original submissions with respect to this issue are maintained [10].
Matters Going to the Administration of Justice (p. 2) Reporting of Likely Deaths to the Coroner
Response when Death Reported to Coroner
In response to the Territory’s submissions, CA submitted that the fact the witnesses did not understand that they had the option to speak directly with Police proves the point that the information was not sufficiently clear [14]. Further, the fact that no item of material detail was identified as ‘forgotten’ may well be because of the loss of detailed recall and is certainly not proof that no loss of recall occurred [15]. This also may have been the result of insufficiently detailed contemporaneous statements.
CA further submitted that: “Whilst the staff of TCH/MHJHADS may not be ‘legally compelled’ to participate in inquest investigations … it is a reasonable expectation of both this Court, but also the community at large, that staff at a government-operated quasi-custodial facility be obligated as a term of their employment to cooperate with the investigation” [17].
Possible Matters of Public Safety (p. 4) Searches/Appropriateness of Patients’ Personal Items (Bearham, Fisher, Lucas)
Assessment of Suicidality and Clinical Risk Assessment (all matters)
Counsel Assisting submitted that, even where there is insufficient evidence to conclude that matters under this section directly contributed to a person’s death, Your Honour is not precluded from making comments or recommendations on these topics [25].
CA submitted that, in respect of Ms Fisher, the Territory “cannot point to bed block as the reason Ms Fisher was not moved to the AMHU but then deny that her unintended lengthy stay on the MHAU without fulsome assessment and commencement of treatment was a critical factor in her ultimate death” [26].
Response to Ligature Risk
Possible Recommendations (p. 7)
Regarding the suggested changes to the Operational Procedure ‘When Death Occurs’, CA submitted that sufficient exemptions apply within privacy legislation to permit the disclosure of information where it is required for law enforcement purposes [30].
CA reinforced their submission that Your Honour should recommend the creation of a formal accountability and governance process [31].
Possible Section 55 Notices (p. 7)
Comments Regarding Counsel Submissions On Jurisdiction
I have considered Counsel’s submissions and will comment on them where required.
I have set out the Jurisdictional limits in respect to a Coroner making comments generally and also where making adverse comments.
I refer to Counsel for the Territory’s submissions in relation to proposed adverse comments pursuant to s 55 of the Coroners Act dated 30 September 2020.
Ms Thomas helpfully set out the power Coroner has to make comments. Pursuant to section 52 (4) (a) in relation to matters of Public Safety arising or found to arise in connection with the inquest. And section 52 (4) (b) any matter about the administration of justice connected with the inquest.
Ms Thomas then sets out the powers and obligations of the Coroner arising out of the inquest such as findings as to identity of the deceased when and where the deceased died in the manner and cause of death pursuant to section 52 (1).
Mr Thomas submitted that any comment the Coroner makes in exercise of the power under section 52 (4) must be connected with the inquest referring back to the objects of the inquest that is to make findings on each of the matters set out in section 52 (1).
This is not contentious.
Ms Thomas then set out the scope of the Coroner’s jurisdiction referring to Harmsworth v State Coroner [1989] VR989 at 997 per Nathan J in relation to a Coroner’s power to make comments pursuant to section 46 (1) their legislation.
The power to comment arises as a consequence of the obligation to make findings… It is not free ranging. It must comment “on any matter connected with the death”… The powers are inextricably connected with, but not independent of the power to enquire into a death… For the purposes of making findings. They are not separate or distinct sources of power enabling a Coroner to enquire for the sole or dominant reason of making comment or recommendation… It arises as a consequence of the exercise of a Coroner is prime function, that is to make “findings”.
I have set out the full paragraph of what Nathan J said below as referred to in Doogan at [41] “Subsection 52(4) also provides that a Coroner “may comment on any matter connected with the death, fire or disaster including public health or safety or the administration of justice.” Comments may obviously extend beyond the scope of “findings”. The latter term refers to judicial satisfaction that facts have been proven to the requisite standard or that legal principles have been established. The former refers to observations about the relevant issues and may extend to recommendations intended to reduce the risk of similar fires, deaths or disasters occurring in the future. However, conferral of the power to make comments does not enlarge the scope of the Coroner’s jurisdiction to conduct an inquiry.”
As Nathan J said, albeit in a somewhat different context, in Harmsworth v The State Coroner at 996: “The power to comment, arises as a consequence of the obligation to make findings... It is not free-ranging... The powers to comment … are inextricably connected with, but not independent of the power to enquire into a death or fire for the purposes of making findings. They are not separate or distinct sources of power enabling a Coroner to
enquire for the sole or dominant reason of making comment or recommendation. It arises as a consequence of the exercise of a Coroner’s prime function, that is to make “findings” …”
Ms Thomas also referred to the decision of Muir J in Doomadgee v Deputy State Coroner Clements [2006] 2 Qld R 352 in relation to a corresponding power pursuant to section 46 (1) of the Coroners Act 2003 (Qld) “[it]… Does not make Coroners roving Royal Commissioners empowered to make findings and recommendations in respect of the matters described in paras (a), (b) and (c)”
Further Ms Thomas submitted that the power to comment on matters clearly serves the purpose of facilitating the making of recommendations by the Coroner on certain matters. I also accept that submission.
Clearly a Coroner must comment on matters relevant to public safety and/or matters about the administration of justice based upon findings that they make in relation to the matters identified. The manner and cause of death is and can be wide-ranging, as set out in paragraph 18 of Ms Thomas’s submissions. That is providing that it is based on evidence which is relevant to those issues.
I also note that Ms Thomas refers to the full Court of the Supreme Court in The Queen v Coroner Maria Doogan; ex parte Peter Lucas-Smith & Ors which cautions against comments made as to the “merits of government policy or the performance of government agencies and private institutions or the conduct of injured visuals even if apparently related in some way to the circumstances in which the death or fire occurred”60.
I have set out the full quotation as it lends to some explanation of what the Judges were concerned with in the appeal at [28-29] “Section 18(1) does not authorise the Coroner to conduct a wide-ranging inquiry akin to that of a Royal Commission, with a view to exploring any suggestion of a causal link, however tenuous, between some act, omission or circumstance and the cause or nonmitigation of the fire. As Nathan J said in Harmsworth v The State Coroner, such discursive investigations might never end and hence never arrive at the findings actually required by the Act. It would also be difficult to contain such inquiries within reasonable bounds whilst at the same time ensuring due fairness. Once evidence of a particular issue was admitted, those who feared that such evidence might form the basis for adverse comments concerning their conduct would inevitably wish to challenge it and to call other evidence to rebut or qualify it. Yet the admission of further evidence might raise further issues and hence generate applications for still more evidence to be called. Thus, a Coroner might be constantly torn between the need to contain the scope of the inquiry and the need to ensure that all interested parties were treated fairly. More fundamentally, the section does not confer jurisdiction to conduct inquiries of that scope.” “A line must be drawn at some point beyond which, even if relevant, factors which come to light will be considered too remote from the event to be regarded as causative. The point where such a line is to be drawn must be determined not by the application of some concrete rule, but by what is described as the “common sense” test of causation affirmed by the High Court of Australia in March v E & MH Stramare Pty Ltd (1991) 171 CLR 506. The application of that test will obviously depend upon the circumstances of 60 Submissions paragraph 22
the case and, in the context of a coronial inquiry, it may be influenced by the limited scope of the inquiry which, as we have mentioned, does not extend to the resolution of collateral issues relating to compensation or the attribution of blame.”61
The comments I have made in relation to this inquest are inextricably linked to the manner and cause of death and go to recommendations that I must make in respect to those matters which I considered to be a matter of public safety or, a matter about the administration of justice.
I have done so considering what the full court said in Doogan at [31] “There will, of course, be many cases in which the issue of causation will necessarily involve an examination of a person’s conduct. A coroner conducting an inquest into the death of a person may be obliged to consider whether the death was attributable to accident or homicide… If that situation does not arise, the coroner will be obliged to make findings as to the nature of the acts and/or omissions that caused the death, even if they reflect adversely on the reputation of one or more people involved in the relevant incident. Hence, a coroner might well hear evidence suggesting that a cyclist’s death had been caused not merely by a collision with a motor vehicle, but also by the antecedent conduct of the driver of that vehicle in failing to stop at a stop sign adjacent to an intersection. However, the limited jurisdiction conferred by s 18(1) would not authorise the coroner to inquire into any perceived failures in relation to general policy relating to the siting of stop signs or the enforcement of traffic regulations. The particular siting and design of the relevant intersection may be a different matter. The application of the common-sense test of causation will normally exclude a quest to apportion blame or a wide-ranging investigation into antecedent policies and practices.” Issues
The obvious question to be answered in this inquest is how could three patients die in modern, specifically designed mental health units within the Canberra Hospital Campus as a result of suicide by hanging?
Further, all 4 patients the subject of this inquest were clearly at risk of suicide, yet they were able to facilitate their death whilst an inpatient at the TCH campus. All 4 patients were to be observed for amongst other things that risk. In at least 2 of those deaths failure to properly observe those patients resulted in them taking their own life. [Lucas; ARC observations and Fisher; failed to observe she had a dressing gown cord]
I have also noted the accreditation review (NSQHS Standards Survey) conducted at the facility and the resulting ‘not met report’. The authors of that report were scathing in relation to how nothing (appeared) to have been done in order for the risk to be minimised after Mr Bearham’s death. I note all four deaths occurred between January 2015 and November 2016.
Having considered the evidence and Counsel submissions I note below the issues which in my view have been squarely raised and which require comment.
61 The Queen v Coroner Maria Doogan & Ors; ex parte Australian Capital Territory [2005] ACTSC 74.
Mechanisms for successful suicide
Availability of Ligature points (door handles) and ligatures (bed coverings, dressing gown belts).
Inadequate observations of patients who were clearly suicidal e.g., Ms Fisher was wearing a dressing gown with a belt attached. Ms Fisher had another dressing gown in her possession which also had a belt attached. Mr Lucas’s observation time change was not reported which gave him a greater opportunity to hang himself. Mr Bearham was agitated when he returned from leave yet was not reviewed by the medical team.
The 3rd floor balustrade with glass cabinet beside it was used to climb over the balustrade enabling Ms Douch to easily jump to her death.
Observations and Safety Checks Issues Ms Fisher
It appears that no staff observed that she had a belt on her dressing gown. That belt was used as a ligature to facilitate hanging herself. One nurse failed to properly check on Ms Fisher at 09.00 by actually sighting her and evaluating her demeanour. There appeared to be a failure to record observations on the ARC chart as well.
It also became evident that the ‘search policy’ was not well understood by staff. The policy had a caveat in relation to the AHMU and MHAU in that if patients refused to be searched, they could be either refused admission or searched involuntarily after consultation with the psychiatric team as well as other options.
I also note that the ARC observation chart clearly states that patients with 2.5 ARC (staff) must be; ‘Aware of patients whereabouts, to be sighted every 30 minutes.’62
I have reviewed the ARC chart and note that the entry at 08:30 hours was not filled in.
RN Robson said that he conducted the observation despite it not being recorded on the observation sheet.
The ARC observations should have been randomised as per the observation protocol which is apparent on the document. Patients should be sighted as part of the observation process. I note Professor Large opined that observations are more than merely sighting a patient, it is about engaging with the patient. It is about observing their mental health state. That was clearly not done in this case.
It was apparent that observations in at least two of the deaths did not always involve actual sighting of a patient. That was a significant failure in my view and fails the purpose test. Why conduct an observation of a patient and not check to see them physically and make an enquiry as to their mental health state.
Mr Lucas
Mr Lucas had his observation status changed. That was not reported, and no change was made to the ARC. RN Eldridge failed to change the ARC score from hourly to half hourly on Mr Lucas observation sheet
Clearly his psychiatrist was concerned about his mental health state. Clearly, he required more constant monitoring. The failure to conduct more frequent observations 62 Transcript of proceedings dated 4 September 2018 (p 134-135).
gave him better opportunity to successfully hang himself. I note that Mr Lucas was successfully resuscitated after hanging himself on the bathroom door. A question remains as to whether he would have been saved had he been observed more frequently as he should have been.
Mr Bearham
Mr Bearham had a drug found on toxicology. A question remains as to how the drug was able to be found in his system. Did he bring it with him? Or had he taken whilst on leave from the Unit?
That same question can be asked in relation to Mr Lucas. There were two empty bottles of alcohol found in Mr Lucas’s room. There is a question of how the bottles came to be there during his admission as a patient at the AHMU. With one possible explanation being that he brought them within into the Unit following day leave.
Mr Bearham returned from leave in a state. Nurses did not advise the Registrar on call because he was too busy and there was a perception by the nursing staff that they would be the subject of adverse comments if they contacted the Registrar.
Ms Douch
Doors and Door Hardware
In relation to the Fisher, Lucas and Bearham matters- Why was it not obvious to anyone that the handles used at AMHU and MHAU were of a poor design? That was my view from the moment I saw the handles at my first visit to the AMHU and MHAU.
I note that Dr Ahlin also shared that view. Dr Ahlin said that he had worked in Units where they had recessed door handles and believed the door handles at the AMHU were clear ligature risks.
Should the hospital have been more diligent in ensuring that the design of the handles was designed in such a way as to be ligature proof? I asked that question because the evidence revealed that the door handle used by Mr Bearham was changed almost immediately following his attempted and ultimately successful suicide.
The handle was changed to a recessed type which did not have a ligature point. It appears that was done within 24 hours of his attempted suicide.
I understand that several of those door handles were replaced with recessed handles in the social area of AHMU. Those types of handles should have been replaced throughout the entire facility as a matter of urgency following the death of Mr Bearham in my view.
There was no clear evidence as to why replacing the door handles earlier than they were would not have been possible.
It should have been clearly obvious that when people are desperate in their mental stress and confusion that they will use invention to achieve their goals. Given the handles were supposed to be designed as non-hanging ligature point’s I can only
surmise that the designers had no experience with this aspect of design and did not think with the same clarity of someone experienced in treating patients who are suicidal.
I note that Mr Golding said that in Royal Darwin Hospital there are no doors capable of being locked and all have recessed handles.
The doors in use at the AMHU and on the MHAU were capable of facilitating a method of ligature point as used by Mr Lucas and possibly Mr Bearham. The doors enabled the use of a bed sheet or blanket being rolled up to be shoved between the door and the door jam, thus providing a ligature point.
I am unsure as to what input staff who work in the mental health area had in respect to the design of the facility. More importantly whether they had any input into the design of the door hardware. I understand that the type of door handle on the doors in the ensuite and bedrooms were used because they were ‘so-called’ anti-ligature handle.
I noted that when I made my first site visit to the Adult Mental Health Unit, prior to being appraised of any circumstances as to the four deaths, that I considered those door handle to be dangerous. It seemed to me that it was common sense that they could be used as a ligature point and used in the way that they were ultimately used by two if not three of the patients who hanged themselves.
Clearly there were other types of door furniture which would have been more suitable.
That is clear from the evidence in the hearing in relation to Mr Bearham where upon him being transferred to the Intensive Care Unit within 24-hour the door furniture was removed and a recessed door mechanism was put in place which was in my view a real anti-ligature piece of door furniture.
As I understand it there was a process in place to replace them ultimately, yet that had not been done in 2018 when I visited the site.
I note that all door hardware has now been changed to recessed types and doors have been changed to ensure that no ligature points are available.
I commend the Directorate for the work they have done in facilitating safer facilities for at risk patients at the TCH campus.
Comments re the taking of witness statements –
Constables Norman and Best gave evidence as to their perceived difficulty in relation to scene preservation and access to witnesses.
In relation to witness statements it appeared from the evidence that once the draft statement had been prepared it was then sent back to Ms Hemming for (checking). It was never clearly explained what that process was although the inference I drew was that it was merely for review of the statement for the purposes of checking spelling, punctuation, and the like.
This does not appear to be a satisfactory way of collecting this information on behalf of the Coroner. That conclusion was reinforced in my mind particularly after hearing the evidence from Dr Cole. Dr Cole had spoken to the Police only an hour or two after the death of Ms Fisher. It was clear from that evidence that RN Matsika had told him that Ms Fisher had not been seen since 9 o’clock that morning. Police recorded his evidence, so I am certain as to what he actually said to Police that day.
When Dr Cole gave his evidence before me, he resiled from the assertion that he had been told by RN Matsika it was 9 am and suggested that it was his interpretation of what he had been told rather than an actual recall of what was said. I note his statement was given some years after the event, despite agreeing that his memory would be much better at the time rather than years later he was able to recall that it was his interpretation rather than the actual words.
Given Dr Cole’s statement was prepared by the Government Solicitor’s office some years later, I have come to the sensible conclusion that the statement which was a recorded by Police at close to the time of the actual event is more reliable than anything he might recall some years later when spoken to by the Government Solicitor about what happened some years before.
I note that the Government Solicitors who assist in this way are not trained investigators nor are they trained specifically on coronial investigation process. I also note that both officers were acting under the authority of the Coroner at the time of their investigation.
The method used by the Department to advise staff members who are potential witnesses, was explained by Ms Hemming. [see paragraphs 787 to 801 above.] I have considered the emails she sends out to the staff asking for cooperation. Ms Hemming agreed that the rewording of the protocol ‘When a Death Occurs’ should reflect an encouragement of staff to assist the Coroner’s investigation. It was accepted by Ms Hemming that the email should contain words to the effect that staff should be encouraged to speak to Police acting on behalf of the Coroner.
There is no doubt that witness statements should be taken as soon as possible. It was accepted as a proposition that memories fade with time.
Identifying potential witnesses is paramount. That should be done as soon as possible.
I accept that witnesses can be upset by a patient’s death, but their information may be critical to the investigation. Those witnesses should be treated like any other in similar traumatic events. I accept that their own health should be considered and that they may require a day or so to recover.
It was also accepted that the Government Solicitor is not an investigator and that Police are trained investigators.
It is also clear to me from the evidence that asking Police to submit questions to be answered in a witness statement that is either facilitated by the Government Solicitor or written by them is less effective and cumbersome than a process of obtaining a direct statement or conducting a Record of Conversation.
There are a number of reasons why it is less effective. The Coroners investigating officers are trained investigators acting on behalf of the Coroner to facilitate the gathering of timely evidence after a death from relevant witnesses. Those Officers are acting independently on behalf of the Coroner. Those Officers, after investigation or inquiry, are able to ascertain which witnesses are required to give a statement and those who are not required.
They can either take a statement from a witness or conduct a recorded interview if that is necessary. During the course of that information gathering process those witnesses are afforded their rights, including whether they wish to engage an independent solicitor or whether they choose not to speak with Police at all.
Allowing the Coroner’s investigators to take witness statements, means they can be taken in a timely manner whilst memory is still fresh.
The need for toing and froing in relation to what should and should not be in witness statements is reduced because it will only be the independent Coroner’s investigators who compile the evidence.
I note that it was accepted by Ms Hemming that the GSO acts for the Territory and not necessarily for the staff. That is also an important factor in my view.
The solution to that conundrum is for the independent Coroners investigating team to conduct the inquiries and gather the evidence which includes witness statements from members of staff.
I note that a number of the hospital staff witnesses indicated in evidence before me that they would have spoken to Police if they had been asked to. I also accept that Ms Hemming in the email she sends to staff outlines their options which include speaking with Police.
MOU with Police following an inpatient death by suicide
Comments in relation to: Mr Bearham
Mr Bearham should have been reviewed when he returned from leave given the state he was in. It should have been clear that he was affected by something. There was no excuse for nursing staff to avoid calling the Registrar, if a review is required, regardless whether they are busy or not. If a patient requires a review by medical staff that should be arranged as a matter of course.
The door handles were changed because it had been identified that the so-called antiligature door handles were in fact a ligature point.
RN Duffy’s evidence was critical in relation to the exact mechanism of how Mr Bearham was suspended. RN Duffy had little recall of precise information in that regard. This demonstrates another reason why Coroner’s investigators should have access to potential witnesses as soon as possible after the incident the subject of the investigation.
Ms Fisher
The dressing gown belt was used to form the ligature Ms Fisher used in her suicide.63 That failure was recognised by the Directorate. I have made a recommendation in relation to this aspect of patient property searches.
In relation to the assessment received in the MHAU for psychiatric patients not being an ongoing assessment due to the nature of it being a “short stay”, where more frequently it is more than a short stay, this issue has been recognised by the Directorate and the model of care in relation to ongoing treatment for patients awaiting admission into AMHU has changed as a result of her death. Now if in the short stay unit patients receives ongoing treatment which continues until admission to AMHU. This change is to be commended.
In relation to the day Ms Fisher died I note that Dr Wood said she saw her at 08:40 hours and she was found hanging at 09:35 hours. RN Matsika who was tasked to look after her that morning stated that he had seen her at 09:15 hours sitting on a couch.
I note Mr Archer stated he was told that she had not been seen for approximately one hour. Dr Cole in his recorded interview with Police only an hour or so after the death said that he was told by RN Matsika that she had last been seen at 09:00 hours.64 Yet in evidence before me he resiled from that timeframe and that comment. I note that RN Matsika said that he saw her at 09:15 hours.
Ms Fisher was on half hourly observations. Nurse Robson was tasked to do that observation. No note was made of the 08:30 hours observation as it was not filled in.
The observation sheet reveals that the observations were conducted at every other time other than 09:15 hours at half hourly intervals. In fact, over the three days she was in the ward there was no other time when an observation was made other than on the half-hour and hour. Each time she was observed it was recorded as resting in bed.
63 I note that on admission to the ED Ms Fisher was wearing the same dressing gown she ultimately used the belt from to commit suicide – (See Exhibit 24 AA [p 10]).
64 Recorded Interview with Dr Cole (p14) [Q83-84].
There was only one other time that she was seen sitting on a couch and that was when she was speaking with a doctor.
I also note that nurse Robson did not see or speak with Ms Fisher at the 09:00 hours observation. He said that he didn’t see her didn’t even enter the room but look through the observation window. He could not see her and did not enquire whether she was all right. I understand that he presumed she was in the bathroom.
Clearly that was an oversight given the purpose of conducting observations is to ensure that the patient is safe. I also note that it was recommended that the observations be randomised and whilst I accept that that is somewhat difficult for half hourly observations it was clearly not done.
Prior to that she was seen by Dr Ward at 08:40 hours. I note that RN Matsika stated he saw her again at 09:40 hours but then resile from that as the MET team had been called at that time and said it must have been 09:35 hours. As I noted at the time RN Matsika gave evidence before me, that gave Ms Fisher 20 minutes or less to prepare the ligature around the door and around her neck, and successfully hang herself.
The evidence from Dr Cole was that at the time he arrived, he found she was centrally and peripherally cold with fixed and dilated pupils, with early signs of lividity within that timeframe.
Dr Cole specifically named RN Matsika as the person he had spoken to; however RN Matsika denies speaking with any person from the Medical Emergency Team (MET).
Dr Harvey -Smith stated that all staff discussed the events of the morning after the resuscitation had been called off. They discussed RN Matsika saying he reviewed her only 15 to 20 minutes before she was found and how quickly she must have acted.
This contradictory evidence further confirms my view about the taking of statements by anyone other than the Coroner’s Investigators.
I note the reflections by the family of Ms Fisher. Particularly in relation to the length of time for this inquest to be finalised. The court apologises to Ms Fisher’s family for the time it has taken, however given there were four deaths in a short space of time it was considered that all four should be heard together, with a view to examining whether there were systemic failures in the mental health system at the time.
I also note the comments in respect to the various adjournments and the like. The coronal system has now undergone a review and it is hoped that a more therapeutic coronal system will emerge because of that review. The Court has appointed a Coronial liaison officer who is directly responsible for assisting families throughout the Coronial process.
I also note the family’s complaint that the place where they felt their mentally unwell loved one would be safe was the hospital. The family felt let down by staff by failing to recognise that Ms Fisher had a belt attached to her dressing gown. Clearly that should have been recognised by staff and I must say I am at a loss to understand how it could have been missed.
It is also clear that staff failed to check the bag citing privacy issues. I have addressed this issue in comments in relation to whether there were systemic failures.
Ms Douch Effect of Belimumab
Other Comments
It was clear that lack of training in identifying a suicidal patient, together with heavy patient loads, insufficient time to write comprehensive notes or to contact specialist teams about concerns indirectly contributed to Ms Douch’s death. I note that Ms Douch was in a medical ward being treated from multi-organ failure. The focus appeared to be on her physical condition and pain management.
It was clear that Ms Douch did overdose because of the intractable pain she suffered, but it should have also been clear that she had intended to suicide because of it. That pain remained intractable on the ward, therefore the suicide risk remained.
The conversation with RN Karia clearly identified that Ms Douch had attempted suicide because of the pain. Even with the (limited) information given by RN Karia, there was no recommendation that she be seen by psychiatric staff for review. Clearly RN Karia was concerned by what she was told by Ms Douch. RN Karia had written in the notes the conversation. Unfortunately, it was not picked up as a concern in relation to her mental health but rather her intractable pain and no psychiatric review was conducted.
I am unable to ascertain why Ms Douch lied to Dr Regna and why the family backed up her story, given they knew about the note she had written. Clearly a whole number of factors and circumstances played against Ms Douch.
Firstly, the overdose, then the note which had been discovered. Some staff knew about it and did not relay that information. The note was on the medical file yet was not noted.
Also designed to play against Mrs Douch was the fact that her pain was increasing because of the reduction in pain relief because of her medical condition from the overdose. Then there was the conversation with RN Karia, clearly that should have been acted upon and a further review undertaken however that was not done.
Would any of those factors having been changed made a difference? It is difficult to say however had the note been seen as a suicide note in the conversation that Ms Douch had with RN Karia and had RN Karia advised the psychiatric liaison service, Dr Regna’s view of her condition may have been different.
Dr Regna said the treatment may have been the same, but it may well have been different and most likely she would have been detained involuntarily and/or given oneon-one nursing care. Dr Regna said with the benefit of hindsight if the Emergency Department continuation sheet was in the folder when he looked at it, he would have brought that up with Ms Douch notwithstanding that the outcome of that conversation could not be predicted.
Dr Regna gave evidence that he would have made an attempt to see the note itself physically and would have then asked pertinent questions of the patient. Dr Regna considered that the note was evidence of suicidal intent at the time of her overdose.
One option for him would have been to detain her on an emergency basis under an emergency detention order.
It is my view that all staff should read all of the notes carefully including the admission document from the Emergency Department. I note that the information in relation to the suicide note was on the very first page in the Emergency Department continuation sheet.
Having said that Dr Swaminathan viewed the overdose as a serious intentional effort at suicide because of her pain. Ms Douch told him she had no further self-harm ideation so that the one on one nursing was discontinued.
Dr Swaminathan also commended Nurse Karia for spending so much time speaking to Ms Douch. I agree because that is what should happen with mentally unwell patients.
In my view that is part of the treatment. The problem is that Nurse Karia did not reveal all the information confided to her by Ms Douch. I accept that Dr Swaminathan took the view that her condition could have changed at any time and the real focus in the unit was about managing the physical manifestations of the withdrawal from drugs as a result of her overdose and resulting kidney and liver failure.
It was clear from RN Karia’s evidence that she had not seen the note on the file although it was there. Nurse Karia also admitted that she had not read the full file given her workload. It was her view that staff do not have sufficient time to review all of the notes and they rely on the hand over in relation to their patient’s history.
Clearly if the handover is inadequate the lack of information is perpetuated. This needs to be addressed.
RN Karia indicated that training in identifying risks to patients on this ward would be beneficial given they are not trained in mental health issues. It is clear this would be of benefit particularly given that RN Karia was made aware that the attempt at suicide was not as a result of just the pain but that she wanted to end her life. This should have been communicated to the medical team looking after Ms Douch. It is clear such an important matter such as the issues raised in the conversation between Ms Douch and Nurse Karia must be disclosed, privacy does not come into it, as the safety of the patient is of paramount importance and issues as to their safety should be communicated to the appropriate staff and written in the notes. Further training in relation to this issue may assist staff in identifying whether disclosures made to them should be disclosed.
I note that Nurse Shepherd considered that better staffing numbers were required to monitor high risk patients and a lockdown ward for these types of patients would reduce the risk of self-harm.
Comments re Mr Lucas
An issue was identified as a result of nursing staff failing to change the ARC score from hourly observations to half hourly observations. That came about because the person who co-signed the document was not the nurse with the care of Mr Lucas.
RN Eldridge was the nurse who co-signed the change in the ARC score. She could not recall the incident but stated her usual practice was to advise the team leader as well is the nurse looking after the patient.
The documentation show that the MGAGIC notes that she completed showed she had written ARC 2 not ARC 2.5. Further on the ARC observation chart she had recorded
that she did the observations at 10:00 hours 14:00 hours, 23:00 hours and 24:00 hours and they were all hourly observations.
It is clear from this evidence that she had not advised the team leader or RN looking after Mr Lucas of the change. This was a clear breach of the usual practice. I note that she also failed to notify a change on 16 November. That had been reflected in a ‘Riskman’ report.
Clearly there needed to be a change in the way changes to the ARC score is reported.
I note that in evidence before me changes have now be made to ensure that any ARC score changes are available on the patient’s file. The protocol has been reviewed to ensure the changes are conveyed to the treating team.
I note that RN Eldridge was never offered the opportunity to speak with Police and indicated that had she been given that opportunity she would have been happy to do so. I also note RN Eldridge said that her statement was drafted by the ACT Government Solicitor. That statement was taken in recent times and not close to Mr Lucas’s death.
RN Ngor gave evidence about finding Mr Lucas hanging from the door in his ensuite.
He stated that a bedsheet was tied over the (so-called) anti-ligature handle over the top of the door and on the other side providing a method for hanging himself.
Neither nurse attending was able to open the door. It took some time to slip the ligature from the handle in order for the door to be opened. It was also noted there was a chair in the bathroom. It was this chair which Mr Lucas used to enable him to hang from the door.
The evidence suggested RN Ngor lacked training in the functionality of the cat and kitten doors used in the facility because he was unaware of how to open the cat and kitten door.
There may have also been lost time in relation to removing the ligature given RN Ngor was not aware of how to open the cat and kitten door. I note that Mr Lucas was successfully resuscitated and taken to the Intensive Care Unit where he ultimately died.
Only senior staff have keys to the cat and kitten doors. This poses a problem in my view as precious time could be lost finding someone who has keys.
In relation to the CRA and ARC forms it may be beneficial to have only one containing the assessment and ARC level. There also needs to be a practice and procedure that reflects whoever witnesses the change in level must report it to the team leader and the person looking after the patient.
The opportunity for Mr Lucas to hang himself was increased because he had longer time to contemplate and then action his death. This opportunity was as a direct result of the ARC score not being changed. Had the observation times been changed and actioned the opportunity for Mr Lucas being successful in his suicide may have been reduced. I say this noting that Mr Lucas was able to be successfully resuscitated.
I also considered that the consumption of 2 bottles of alcoholic spirits may have emboldened him as well. It is a mystery as to how these bottles were able to be secreted in his room and not located by staff.
Comments in relation to issues raised about access by Police to witnesses
There was a disputed about that matter and some staff denied that he was refused permission or that they were asked to contact the on-call Director.
There was also evidence of different views in relation to investigating deaths at the TCH complex. Particularly in relation to the gathering of evidence and provision of statements.
It appears to me after having very carefully considered the evidence from all of the witnesses, there is a tension between on the one hand Police wishing to conduct an investigation on behalf of the Coroner and the Directorate on the other wishing to support their staff.
It also appears that there is a misunderstanding between the two as to what should occur after a death. Ms Hemming, utilising the current operating practice which had evolved when these deaths occurred, did not immediately give details of any potential witnesses who may have witnessed an adverse event. Ms Hemming’s practice is to collate the information such as who was working and whether they might need to give a statement and she will then send an email to staff giving them options with includes an option to speak with Police. Those options involve explaining that the GSO acts on behalf of the Department and does not act on behalf of an individual. Ms Hemming stated that she also advises that cooperation is usually recommended but her experience is that predominantly the preference of staff is to do statements rather than speak to Police.
I note Ms Hemming said she did not express the view to anyone that she would not give information such as contact details for witnesses. That is clearly not the understanding of Constables Norman or Reynolds. In the Fisher matter Constable Best said she was told staff would not give her statements or records of conversation that day but that she could speak to senior staff if they were agreeable. That indeed occurred because Dr Cole was interview by Police which was recorded. It was also noted that the directly relevant witnesses had gone home for the day because of the death.
I also note that a number of witnesses did say that they would have spoken to Police had they been asked and some said they don’t recall receiving an email with the options as stated by Ms Hemming.
The process appears to be quite clunky and could mean that this was an unsuccessful way of communicating the options available to the potential witnesses.
These misconceptions could easily be addressed by a comprehensive policy on what the expectations are in respect to staff assisting the Coroner. This requires a coordinated and cooperative approach to the subject. I propose to recommend that a review of the MOU between mental health and the Australian Federal Police and the inclusion of the Coroner’s office in that MOU be considered.
In keeping with the comments in relation to the misconceptions cited above I also note that there was a delay in relation to the provision of statements, in particular in relation
to the Lucas matter the delay was substantial. This issue could be addressed by the memorandum of understanding that I have considered above.
During the period when these four deaths occurred, in relation to 2 of them Police were not notified of non-survivable self-inflicted injuries to patients. In Mr Bearham’s case, Police were not notified nor was the incident scene preserved after he was able to be successfully revived for a short period of time. The consequence of that fact was that key evidence, namely the linen and bucket/bin that Mr Bearham used in his suicide attempt, was not preserved. I am satisfied that the failure to preserve evidence was not done with malicious intent, and in the circumstances overall the absence of that evidence is most likely of little consequence. In my view it would have been better that that material was secured given the dire circumstances predicted for Mr Bearham.
I note that CHS now has a policy of notifying Police at the time of the event where a patient has a non-survivable self-inflicted injury. I also note that securing of potential evidence is also part of that policy.
Concluding remarks
This has been a difficult inquest on any view. 4 in- patients at The Canberra Hospital Woden complex died in a relatively short period of time. 3 suicides by hanging and one suicide by a fall from a height.
The hospital failed those 4 patients and their families insofar as, all 4 patients were admitted to the Hospital as a result of their significant risk of suicide. All 4 patients required appropriate observations of them to ensure their safety. Some of the reasons for the failures are set out in my remarks above. The themes of difficulties with staffing, insufficient on-going staff education and insufficient attention to protocols, practice and procedures can be identified as either failure of the implementation of policy and practice or inadequate policy procedures. Those issues were identified in the Accreditation Review as systemic failures. I have also exposed a number of those failing in my remarks above as they relate to the four deaths the subject of this Inquest.
Whilst it is accepted that standards have risen since these unfortunate deaths, the AMHU and the hospital were not performing to the standard required as identified clearly in the review for accreditation.
I acknowledge that running a health facility is not an easy task and there are many competing interests at play. A focus on patient safety particularly in the mental health arena is one of primary focus for mental health facilities. This focus needs to be enshrined in all practice, procedure, protocols and educational training. Having said that, I note that there have been significant changes made to the practice and procedure in relation to mentally ill patients in both the short stay unit and the AMHU. I also note that training has been updated and more training is now being given to the nursing staff.
That is to be commended.
It is noted that since the changes to some of the Practice and Procedure as well as changes to staffing levels, more education, better handover procedures and minimising ligature risks, no lives have been lost since Mr Lucas’s death in 2016. That is also to be commended.
I have no doubt that the staff at The Canberra Hospital work very hard to ensure the safety of their patients. It is clear from the evidence before me there are difficulties in relation to obtaining sufficiently trained staff in mental health. I heard evidence in relation to it not being unusual for nursing staff to work double shifts and that it happened on a reasonably regular basis and happened at the time of these deaths.
I also recognise that patients with mental illnesses can be difficult to treat and despite appropriate treatment cannot always be saved. However, I also recognise that families expect that their loved ones are safe in treatment facilities. That is particularly true at The Canberra Hospital. I say that because the AHMU was a relatively new unit with many features included to ensure that patients feel comfortable in a setting of good amenity, with open spaces and clean and airy rooms. I note that Professor Large commented on the facility as being the gold standard.
I am unsure as to what input staff who work in the mental health area had in respect to the design of the facility. More importantly whether they had any input into the design of the door hardware. I understand that the type of door handle on the doors in the ensuite and bedrooms were used because they were ‘so-called’ anti-ligature handle.
I noted that when I made my first site visit to the AMHU, it was prior to being appraised of any circumstances as to the four deaths. I considered those door handle to be dangerous. It seemed to me that it was common sense that they could be used as a ligature point and used in the way that they were indeed used by at least 2 and possibly 3 of the patients who hanged themselves.
Clearly there were other types of door furniture which would have been more suitable.
That was clear from the evidence in the hearing in relation to Mr Bearham where upon him being transferred to the Intensive Care Unit, within 24-hour the door furniture was removed and a recessed door mechanism was put in place which was in my view a real anti-ligature piece of door furniture.
Yet in respect to the other door handle in the facility those were not changed. As I understand it there was a process in place to replace them ultimately, yet that had not been done in 2018 when I visited the site.
During the course of this Inquest several issues have been identified. Several of them have already been addressed by the Directorate who are to be commended for those improvements. I note that extensive changes have been implemented to ensure patient safety.
I have also made several recommendations as to issues going to the safety of the public.
I issued two Section 55 notices (Coroners Act 1997) in relation to proposed adverse comments. I have set out those comments below.
I wish to thank Counsel Assisting me. Ms Baker-Goldsmith and Mr Kamarul have worked tirelessly throughout the proceedings. I would also like to thank Ms Thomas, Counsel for the Territory. Ms Thomas was very professional and competent in her conduct in the proceedings and provided comprehensive submissions as well. Ms Thomas and her team also assisted with the provision of the information in respect to improvements to the mental health inpatient wards as well as implementation of those changes.
I would also like to thank the families of Mr Bearham, Ms Fisher, Ms Douch, and Mr Lucas for their patience in waiting for me to complete my findings. It has taken a lot longer than I anticipated and I apologise for that fact. I would also like to share my condolences and that of the Court to their families.
Section 55 Notices
I have issued S55 notices to Canberra Health Services and RN Sara Eldridge.
I have made several comments in respect to the evidence before me in this inquest.
Those comments have been made available to the Territory for comment. I have carefully considered the submissions made by the Territory in light of my proposed comments and have reviewed my comments in light of those submissions received.
I have also attached the submissions made by Counsel and statements provided by them as required pursuant to S55 in respect to adverse comments.
I also attached submissions to the comments I have made in respect to the evidence which is not adverse to anyone but has been the subject of question as to the accuracy.
TCH Adverse comments
“The TCH policies outlining procedures for the searching of consumer’s person or property, and the staff training on such policies, at the time Mr Bearham, Ms Fisher and Mr Lucas died were inadequate given that in three of the cases, Bearham, Fisher and Lucas items detrimental to their safety were ultimately found. Those were that Mr Bearham had methamphetamine in his toxicity screen, Ms Fisher had a dressing gown belt used to facilitate her suicide and Mr Lucas was found to have two empty alcohol bottles under his mattress.
In the case of Ms Fisher, I find specifically that she should not have been able to retain her dressing gown belt, and the failure by multiple staff to have noticed it and remove it was a contributory factor to her death. 65 It is difficult to understand how it was missed by staff who had been keeping a close observation of her every 30 minutes.
In relation to Ms Fishers treatment, having considered the evidence, in my view It was inappropriate and undesirable for Ms Fisher to have remained on the MHAU for as long as she did without any active psychiatric treatment or comprehensive assessment for suicidality. I acknowledge the difficulty of the individual practitioners involved in treating Ms Fisher in relation to bed block at the AMHU and Ms Fisher’s refusal to engage with them.
However, I find that the failure to reassess Ms Fisher for suicidality may have been a contributory factor to her death. I acknowledge that shortly after Ms Fisher’s death the Chief Psychiatrist directed that MHAU patients were to be reviewed at least every 24 hours and I commend this change to procedures.
In Mr Lucas’s case, a staff member failed to properly record his ARC levels and observations of him were carried out less frequently than had been directed by the Consultant Psychiatrist. TCH’s systems provided no opportunity to identify or correct the error. While this cannot be said to have been a direct contributing factor to Mr Lucas’s death, it provided him with a greater window of opportunity in which to commit self-harm, as well as limiting the opportunity for Mr Lucas to have been discovered midact and potentially diverted.
65 Given that was the mode used to suicide.
The response of ACT Health to dealing with issues of ligature risk was inadequate and belated and represented a systemic failure. Although efforts were made after Mr Bearham’s suicide attempt to alter the door handle of the specific room in which he made his attempt, nothing was done in relation to other door handles which were of similar design, in the AMHU or MHAU other than the Social Spine. 66 The method of using a closed door as a ligature attachment point was known to ACT Health before Mr Bearham’s death, and then Ms Fisher completed suicide using a similar method. ACT Health did not take any significantly active steps to mitigate ligature risk across mental health inpatient facilities until after Mr Lucas’s death, and even then, not until there was a risk of TCH losing facility accreditation.” 67 Sara Eldridge
“You failed to follow the usual practice in relation to recording and implementing changes to Mr Lucas’s ARC score on 12 November 2016. As a consequence of your failure, Mr Lucas continued to be observed by you and others on an hourly basis, when a Consultant Psychiatrist had decided that Mr Lucas’s condition warranted more frequent observation. Your failure increased Mr Lucas’s window of opportunity to engage in self-harm, although it was not directly contributory to his death.” 66 See for example exhibit 16 and 17 of Phase 11 67 NSQHS Standards Survey – Not Met Report (p 8).
Recommendations
(a) That a review of the MOU between TCH and the AFP be conducted, with a view to simplifying and clarifying the process of Police having access to staff who are potential witnesses where a death occurs.
(b) That a review of TCH Operational Procedure ‘When Death Occurs’ be made with a view to incorporating policy and procedure. As well as clear directions that staff should be encouraged to engage with Police investigating a death at the TCH campus on behalf of the Coroner.
(c) That there be a review of policy and procedure in relation to dangerous items brought in by patients (particularly those at risk of suicide), including clear procedures for searching of patients for those items and clear procedures for when resistance to those searches is met.
(d) That there be a review of possible technological equipment for monitoring of at-risk patients, such as pulse oximeters and CCTV in general areas of the facility.
(e) Review training in relation to the ‘at-risk observation’ policy and procedure to ensure staff understand the reasoning behind the policy and the importance of its adherence to it.
(f) TCH finalise the MHSSU Operational Procedure as soon as practicable, having regard to the evidence lead in this inquest and the suggestions for changes and additional training put forward in respect of this and the AMHU Operational Procedure
(g) That MHJHADS should consult with its staff and review its training packages to ensure that the training provided is appropriate and fit for purpose.
FINDINGS Anthony Leigh Bearham
Nicola Joy Fisher
Christine Belle Douch
Ken Alexander Lucas
CORONER M.A. HUNTER OAM I certify that the preceding one thousand two hundred and twenty-nine [1229] numbered paragraphs are a true copy of the findings of Her Honour Coroner Hunter Associate: G Price Date: 04 March 2021
IN THE CORONERS COURT AT CANBERRA IN THE AUSTRALIAN CAPITAL TERRITORY INQUEST INTO THE DEATH OF ANTHONY BEARHAM INQUEST INTO THE DEATH OF NICOLA FISHER INQUEST INTO THE DEATH OF CHRISTINE DOUCH INQUEST INTO THE DEATH OF KEN LUCAS STATEMENT OF MICHELLE HEMMING
On 2 February 2021, I Michelle Hemming, of 1 Moore Street, Canberra, in the Australian Capital Territory, state:
This statement truly and accurately sets out the evidence which I would be prepared, if necessary, to give in court.
I am a Legal Policy Officer within Mental Health, Justice Health and Alcohol and Drug Services (Mental Health).
The Coroner in each of the inquests into the deaths of Anthony Bearham, Nicola Fisher, Christine Douch, and Ken Lucas (Inquests) has given notice that her Honour is considering including the following comments in a finding or report under the Coroner’s Act 1997: (1) In at least three of the four deaths, treating staff gave evidence that they were not aware they could speak to police officers who were investigating the deaths on behalf of the Coroner and some had not read the email that you had sent them regarding their options to make statements. You also refused to provide Police with contact details for individual staff.
While I am satisfied that there was no intention here to impede the course of justice, nevertheless these actions impeded the timeliness and effectiveness of the coronial investigations.
(2) There has apparently developed a practice, in which you are a key player, whereby statements from CHS staff in coronial matters are not taken by Police but are prepared by the ACT Government Solicitor and delivered to Police often much later. In both the Bearham and Lucas matters in particular, this practice hampered and delayed the coronial investigations. Significantly, statements provided were not necessarily directed to issues of concern for the Coroner, nor were they provided in a timely way in all cases.
I attended the hearing of the Inquests. I did not recall any witness giving evidence that: (1) they were not aware they could speak to police officers who were investigating the deaths on behalf of the Coroner, and (2) they had not read the email that I had sent them regarding their options to make statements.
When Mental Health staff are identified as potential witnesses in relation to a coronial investigation, it was my practice to: (1) encourage staff to cooperate with the investigation, and (2) if requested by Police, encourage staff to participate in a record of interview with Police.
I have not been asked by Police to provide contact details for staff. I have not refused to provide Police with contact details for staff.
I am not aware of a practice whereby statements from Mental Health staff in coronial matters are not taken by Police but are prepared by the ACT Government Solicitor and delivered to Police often much later.
Prior to the deaths the subject of the Inquests, to the best of my recollection, there had not been a patient death at an inpatient mental health facility for more than approximately 10 years.
I understand that Police do not have a consistent practice for obtaining statements. From the inquests that I have been involved in, on occasion, Police will attend Mental Health facilities and
obtain statements from ACT Health Directorate staff by undertaking records of conversations. I am aware of a number of occasions where staff have refused to participate in interviews with Police.
This statement is true and correct to the best of my knowledge and belief and I make it knowing that, if it is tendered in evidence, I will be liable to prosecution if I have wilfully stated in it anything that I know to be false or do not believe to be true.
I read this statement before signing it.
__________________________ Michelle Hemming Date: 2 February 2021
IN THE CORONERS COURT AT CANBERRA IN THE AUSTRALIAN CAPITAL TERRITORY INQUEST INTO THE DEATH OF ANTHONY BEARHAM INQUEST INTO THE DEATH OF NICOLA FISHER INQUEST INTO THE DEATH OF CHRISTINE DOUCH INQUEST INTO THE DEATH OF KEN LUCAS SUBMISSIONS ON BEHALF OF MICHELLE HEMMING FURTHER REVISED PROPOSED COMMENTS
I note Ms Hemming said she did not express the view to anyone that she would not give information such as contact details for witnesses. That is clearly not the understanding of Constables Norman or Reynolds. In the Fisher matter Constable Best said she was told staff would not give her statements or records of conversation that day, but that she could speak to senior staff if they were agreeable. That indeed occurred because Dr Cole was interview (sic) by police which was recorded. It was also noted that the directly relevant witnesses had gone home for the day because of the death.
I also note that a number of witnesses did say that they would have spoken to police had they been asked and some said they don’t recall receiving an email with the options as stated by Ms Hemming.
The process appears to be quite clunky and could mean that this was an unsuccessful way of communicating the options available to potential witnesses.
Refusal to provide police with contact details
Two police witnesses did not give evidence that they were refused contact details for individual staff after requesting them.
The only police witness to give evidence to this effect was First Constable Norman in relation to the inquest into the death of Mr Bearham. Ms Hemming refers the Coroner to her: (1) outline of submissions of 30 September 2020, [76]-[87], and (2) outline of submissions of 1 September 2020, [18]-[19].
Detective Senior Constable Paul Reynolds (DSC Reynolds) did not give evidence that Ms Hemming (or anyone else within AHMU) refused to provide contact details for individual staff after being requested to do so. No such request and/or refusal is contained in or evidenced by: (1) DSC Reynolds’ statement (2) DSC Reynolds’ correspondence contained within Exhibit CD30, or (3) DCS Reynolds’ oral evidence.
DSC Reynolds’ oral evidence was to the effect that he requested the Coroner’s office of the Australian Federal Police provide the names of the people who would provide witness statements, he was relying upon the Coroner’s office to provide those details, and the Coroner’s office failed to do so.1 He did not, however, give evidence that he requested staff contact details.
Ms Hemming has repeated on a number of occasions that: (1) on no occasion did Constable Norman or any other ACT Police officer ask her for direct contact details for any staff members (2) she did not refuse to provide staff contact details to Constable Norman, and (3) it is very likely, however, that she would have told him that the usual practice was for Ms Hemming to deal with the staff members to arrange an interview.2 The evidence of Senior Constable Best
The further revised comments do not accurately reflect the evidence of Senior Constable Best.
Senior Constable Best’s evidence included, to the effect that: (1) staff would not be provided statements or taped conversations with Police on that day (2) Police could, on that day, speak to staff with a senior staff member present, if the staff member agreed to do so,3 and (3) statements or taped conversations with Police could be organised by Police on another day.4
More significantly, the evidence of Senior Constable Best appears to be relied upon to call into question Ms Hemming’s evidence that she had not been requested by Police to provide, nor had she refused to provide, contact details for individual witnesses. It was clear from the evidence of Senior Constable Best and Ms Plant that Ms Hemming was not, directly or indirectly, involved in the conversations with Senior Constable Best.
Providing police with the names of witnesses
The further revised comments do not accurately reflect Ms Hemming’s evidence about her practices in relation to assisting police with Coronial investigations.
Ms Hemming assists those investigating deaths by responding to their requests. Ms Hemming’s practice is defined by the way that the investigation is conducted. The uncontested evidence of Ms Hemming was to the effect that she did promptly provide the names of potential witnesses when requested to do so by police or the Coroner’s office. There is no evidence to suggest that Ms Hemming did not promptly provide the names of potential witnesses.
As illustrated by the inquest into the death of Mr Bearham, Ms Hemming’s evidence was to the effect that: 1 Transcript 13.4.18, pp 31-32.
2 Exhibit CD 6, Statement of Michelle Hemming dated 24 August 2018 (Hemming), [50]; Statement of Michelle Hemming dated 25 September 2020, [6]; Statement of Michelle Hemming dated 1 February 2021, [6].
3 Fisher, Exhibit CD2 – witness statement of Deanne Jewel Best dated 14 August 2015 (Best), [26].
4 Transcript 20.4.18, p 59, ll 40-44; Fisher, Best, [25].
(1) when requested by the Coroner’s Team or ACT Police to identify the staff who were on shift or provided care and treatment to the deceased person, Ms Hemming responded to this request by reviewing the roster for the date in question to ascertain the relevant staff (i.e.
working in the LDU and not the HDU) and reviewing the deceased person’s clinical records.5 In the inquest into the death of Mr Bearham, after working with police to identify relevant witnesses, on 15 January 2015, Ms Hemming provided Police with a list of staff who had been on duty in the AMHU at the time the deceased was found hanging,6 and (2) the provision of a list of witnesses is usually followed by a request from the Coroner’s Team or ACT Police to either speak with the staff member for the purposes of an interview or for written statements. Ms Heming would then contact the staff member to make the necessary arrangements for an interview or a written statement.7 In relation to inquest into the death of Mr Bearham:
(a) on 21 January 2015, First Constable Norman identified relevant staff,8 and
(b) on 22 January 2015, Ms Hemming sent an email to staff requesting that they indicate by 27 January 2015 whether they wished to participate in a record of interview or otherwise provide a written statement.9 Ms Hemming requested staff’s availability for an interview between 29 January and 4 February 2015. The email attached a template witness statement, and requested that statements be provided by 10 February 2015.
The balance of the inquests illustrate that the approach of Ms Hemming and other ACT Health and Mental Health staff is determined by the way that the police conduct the investigation.
In relation to the inquest into the death of Ms Fisher, First Constable Best identified the relevant witnesses on the day she attended The Canberra Hospital and subsequently requested statements be obtained from specific witnesses.10 There was no occasion for Ms Hemming to identify relevant witnesses.
In relation to the inquest into the death of Ms Douch, police identified the relevant witnesses when they attended The Canberra Hospital. Police subsequently provided a list of witnesses.11 There was no occasions for Ms Hemming to identify relevant witnesses.
In relation to the inquest into the death of Mr Lucas, police simply requested statements be provided for staff present at the time.12 Witnesses being aware of the option of talking to police
The further revised comments are misleading as: 5 Hemming, [18].
6 Norman, [67].
7 Hemming, [20].
8 Norman, [70]. Note, the email is not in evidence and the witnesses were not asked any questions about the contents of the email.
9 Bearham, CD17.
10 Fisher, Exhibit 62.
11 Douch, Exhibit CD73, p 3, email from Rachel Hutka to Jenny Broome cc ACT Coroners sent 10 August 2016.
12 Exhibit CD30.
(1) the only witnesses that gave evidence that they would have spoken to police if they were given the opportunity to do so were in relation to inquests where the police did not want to speak to witnesses (2) the witnesses that gave evidence that they did not recall receiving the email from Ms Hemming either:
(a) believed they would have received and read the email, however, simply did not have a specific recollection 3 years after receiving the email, or
(b) were not sent the email.
Date: 2 March 2021 __________________________ Nigel Oram Counsel for Ms Hemming
INQUEST INTO THE DEATHS OF ANTHONY BEARHAM (CD 8 OF 2015) NICOLA FISHER (CD 61 OF 2015) CHRISTINE DOUCH (CD 164 OF 2016) KEN LUCAS (CD 281 OF 2016) ACT CORONERS COURT SUBMISSIONS OF THE TERRITORY IN RESPONSE TO S 55 NOTICE DATED 25 FEBRUARY 2021 INTRODUCTION
These submissions are made by the Australian Capital Territory (the Territory) in response to the notice dated 25 February 2021, issued to Canberra Health Services (CHS) purportedly pursuant to s 55 of the Coroners Act 1997 (ACT) (the Act). The notice relates to inquests into the manner and cause of death of Mr Bearham, Ms Fisher, Ms Douch and Mr Lucas.
The notice dated 25 February 2021, to which these submissions are addressed, is the third draft of proposed adverse comments provided by the Coroner pursuant to s 55(1) of the Act.
The Territory has been informed that the Coroner intends to hand down her findings on 4 March 2021, which is four business days after receipt of the notice.
As set out below, the proposed adverse comments set out in this third notice: a. contain changes to the wording of the proposed comments that have necessitated a further review of the evidence; and b. include wording that had been the subject of previous submissions by the Territory and had been removed from the last notice issued by the Coroner, without any explanation as to why it has been reinserted.
The Territory has, in the very limited time available, attempted to address, in these submissions, this latest version of the adverse comments that the Coroner proposes to make in relation to it.
Given the changes that have been made to the wording of the comments, the Territory does not consider that it has been given a fair or reasonable opportunity to respond. It reserves its position in relation to the inclusion of these comments in the Findings.
If (or to the extent that) the Coroner decides, after considering these submissions, to include in her Findings the comments as they are set out in the latest notice, the Territory requests that the Coroner also include in the findings the attached statement of Ms Grace, pursuant to s 55(1)(b).
After the hearings concluded in 2018, there was an exchange of submissions between Counsel Assisting and the Territory.1
The first s 55 notice issued to CHS (the first CHS notice) was dated 5 August 2020. It set out comments in eight numbered paragraphs. They addressed the following topics: [1] the belief of witnesses concerning their ability to provide information to officers of the AFP investigating the deaths on behalf of the Coroner; [2] the role of the ACT Government Solicitor in the provision of witness statements; [3] the asserted lack of contemporaneous notes by treating staff; [4] the omission of staff to notify police of the attempt at self harm by Mr Bearham; [5] TCH policies relating to the searching of consumer’s person or property; [6] the asserted lack of a medical review of Ms Fisher while she remained on the MHAU; [7] the recording of Mr Lucas’ ARC levels; and [8] the response of ACT Health to issues of ligature risk.
At the same time, the Coroner issued a notice of proposed adverse comments against Ms Michelle Hemming, a Territory employee. The notice to Ms Hemming related to the matters raised in [1] and [2] of the first notice to CHS.
The Territory and Ms Hemming responded to the first CHS notices in separate submissions dated 30 September 2020.
The second s 55 notice (the second CHS notice) provided by the Coroner was dated 8 January 2021. A second s 55 notice was also provided to Ms Hemming. The second CHS notice included proposed adverse comments in eight numbered paragraphs dealing with the topics referred to in the first CHS notice. Each of the proposed comments in the second CHS notice contained modifications to those that had been included in the first CHS notice. The amendments were said to have been made by the Coroner after considering the submissions made by the Territory and Ms Hemming.
1 Counsel Assisting’s submissions dated 12 October 2018, Territory’s submissions dated 13 November 2018, Reply submissions from Counsel Assisting dated 11 December 2018.
In response to the second CHS notice, the Territory provided a statement of Ms Karen Grace pursuant to s 55(1)(b) of the Coroners Act. Ms Hemming responded to the second notice that had been provided to her in submissions dated 1 February 2021 and a statement dated 2 February 2021.
The third notice that has been issued to CHS, to which these submissions respond, omits entirely any proposed adverse comments dealing with the topics referred to in paragraphs 1 to 4 of the first two notices. The Territory assumes that there will no comments adverse to CHS or the Territory in relation to those topics, included in the Findings in relation to these four topics.
Based on the third notice, the Territory understands that the Coroner continues to intend to include comments that are adverse to CHS in relation to the topics referred to in paragraphs 5 to 8 of the first two notices.
The Territory’s submissions in respect of the proposed comments in relation to those topics are set out below.
In the case of Ms Fisher, I find specifically that she should not have been able to retain her dressing gown belt, and the failure by multiple staff to have noticed it and remove it was a contributory factor to her death. It is difficult to understand how it was missed by staff who had been keeping a close observation of her every 30 minutes.
This is the first occasion in which the proposed adverse comment on this issue has identified, at least in a general way, the evidence that on which it is based, insofar as it extends to the Bearham and Lucas matters.
For the Bearham matter, the basis for this comment is said to be that Mr Bearham had “methamphetamine in his toxicity screen”. For the reasons set out below, this evidence does not provide any basis for the proposed comment, insofar as it relates to Mr Bearham.
Counsel’s Assisting’s opening in the Bearham matter noted that toxicology results from blood tests taken while Mr Bearham was in ICU returned a positive result for methamphetamine.2 The records themselves were not addressed in any witness statement or expert report (including the post mortem report) and the issue was addressed only in passing in Dr Grey’s oral evidence.3 2 Transcript 10 April 2018 page 6.
3 Transcript 10 April 2018 page 92.
Apart from the absence of any focus on the ICU blood results, there is no basis on which this evidence can be linked to any deficiencies in the procedures relating to the searching of consumer’s property or in the implementation of those procedures. Mr Bearham had been permitted leave from the AMHU on 2 January 2015 and could have taken drugs while he was away from the unit. There was no evidence that he brought drugs into the AMHU. There is no evidential basis for linking the blood results obtained when he was in the ICU to any deficiency in the search procedures or in staff training at the AMHU and no evidence to support the proposed comment insofar as it relates to Mr Bearham.
For the Lucas matter, the basis of this comment is that two empty bottles of alcohol were found under the mattress in his room, after his attempt at self-harm.
There was no evidence as to how the bottles (which had contained brandy) were brought into the unit. There was evidence that established that there had been a discussion with Mr Lucas in relation to his belongings and clothing when he was admitted to the AMHU.4 It was not put to any witness that any further or different steps were required by the procedures in place at the time. In fact, there was no evidence that would support a finding that Mr Lucas brought these items into the unit. The evidence of Mr Lucas’ brother and of the medical records was that Mr Lucas did not drink.5 It is possible that the bottles had been left by a previous occupant of Mr Lucas’ room. Whether that was what occurred and whether or not that was linked to any failure to implement the search policy in place at the time was not touched upon at all in the evidence.
The Territory accepts that alcohol should not have been present in the AMHU. However, there is no proper evidential basis for attributing the finding of the bottles in Mr Lucas’ room to a deficiency in the search procedures or in the training of staff in those procedures.
Insofar as the comment relates to Ms Fisher, the Territory accepts that she should not have had the dressing gown belt in her possession. However, for reasons set out in the Territory’s previous submissions, there is not a sufficient evidential basis for concluding that this was due to any deficiency in the search procedures in place at the time6 or any failure to train staff in those procedures.7
5 Transcript of conversation with Ian Lucas, page 15. Patient Health Summary from Watson General Practice, page 1 (“non drinker”).
6 See in particular [169] of the Territory’s submissions dated 13 November 2018 and [154] of the Territory’s submissions dated 30 September 2020.
7 See in particular [170] to [173] of the Territory’s submissions dated 13 November 2018 and [155] of the Territory’s submissions dated 30 September 2020
involved in treating Ms Fisher in relation to bed block at the AMHU and Ms Fisher’s refusal to engage with them.
However, I find that the failure to reassess Ms Fisher for suicidality may have been a contributory factor to her death. I note that shortly after Ms Fisher’s death the Chief Psychiatrist directed that MHAU patients were to be reviewed at least every 24 hours and I commend this change to procedures.
The Territory repeats the submissions that it has already made in relation to this issue8 and notes that a comment concerning contribution to Ms Fisher’s death has been reinserted into the proposed wording.
The first CHS notice contained the words “the failure to reassess Ms Fisher for suicidality [while she was in the MHAU] was a contributory factor to her death” [emphasis added]
In its submissions dated 30 September 2020, the Territory addressed the relevant approach to causation and the evidence. As explained in those submissions,9 there was no evidence, let alone cogent and persuasive evidence, that would support an inference that the failure to reassess Ms Fisher for suicidality contributed to her death.
Having considered those submissions, in the second CHS notice, the Coroner omitted any reference to contribution in the proposed comment.
In this latest notice, however, the Coroner has indicated that she proposes to include a comment that “the failure to reassess Ms Fisher for suicidality may have been a contributory factor to her death” [emphasis added].
For the reasons set out in previous submissions of the Territory, there is no evidence capable of supporting an inference that a further medical assessment of Ms Fisher on 19 March 2015 would have altered the outcome. No ‘counterfactual’ (that is, a consideration of what would have occurred had there been a further assessment) was explored in the evidence. This aspect of the proposed comment does not, therefore, rise above speculation, with no evidential foundation, and should not be included. The approach taken in the second CHS notice, namely to make no comment at all on the question of contribution or causation is, in the light of the absence of evidence, the only appropriate course.
8 At [193] to [202] of its submissions dated 13 November 2018.
9 At [166] to [171].
The modifications that have been made to the wording of this comment as it appeared in the second CHS notice, are not only not justified by the evidence, they introduce confusion into the entire issue, where the evidence of what occurred was not significantly in contest.
The relevant “error” was the performance of hourly rather than half hourly observations of Mr Lucas after his clinical risk was reassessed by Dr Ahlin and Dr Modak on 11 November 2016. This was an error because Dr Ahlin had assessed Mr Lucas’ risk at ARC 2.5, which required half hourly observations. This was appropriately documented but, the evidence would suggest, was not handed over to other members of the nursing staff responsible for performing those observations after Mr Lucas’ medical review.
The paragraph included in the first and second CHS notices on this issue referred to “staff” generally failing to properly record Mr Lucas’ ARC level, rather than “a staff member”. There was no evidence that any single staff member made an incorrect record of Mr Lucas’ ARC level. While the wording used in the first and second CHS notice is not ideal, it is more consistent with the evidence than the wording adopted in the latest notice.
A more significant issue with the proposed comment is the inclusion of the words: “TCH’s systems provided no opportunity to identify or correct the error”. These words appeared in the comment that appeared in the first CHS notice. The Territory’s submissions dated 30 September 2020 summarised the evidence that established that, as at 11 November 2016, there was a system in place at the AMHU directed to ensuring that any variation in a patient’s ARC level my medical staff would be implemented by nursing staff.10 This included a CRA form that was required be signed by both medical staff and a nurse and a requirement that the nursing staff who countersigned the CRA form to the team leader as well as the nurse to whom the consumer had been allocated. While these procedures were not implemented after Mr Lucas’ clinical risk re-assessment, the relevant staff member accepted that she was aware of them.
The Coroner, having considered those submissions, amended the wording in the second CHS notice to say “TCH’s systems provided limited opportunity to identify or correct the error”.
For reasons that have not been explained, in this third CHS notice, the Coroner has reverted to the wording in the original notice. For the reasons set out in the Territory’s previous submissions, which the Coroner appeared to have accepted, this aspect of the comment is not justified by the evidence.
door as a ligature attachment point was known to ACT Health before Mr Bearham’s death, and certainly was known after his death. Ms Fisher completed suicide using a similar method of attaching the ligature to the door handle. Between Ms Fisher’s death and Mr Lucas’ death, ACT Health did not take any significant active steps to mitigate ligature risk across mental health inpatient facilities until after Mr Lucas’ death, and even then, not until there was a risk of TCH losing facility accreditation.
In a footnote at the end of the comment, the Coroner has added a reference to the “not met” report. This is presumably a reference to the Australian Commission on Safety and Quality in Health Care (ACSQHC) Report of March 2018.
The Territory addressed this issue in in [225]-[238] of the Territory’s submissions dated 13 November 2018 and has specifically addressed a previous version of this comment in [185] to [207] of its submissions dated 30 September 2020. The Territory repeats and relies upon those submissions.
The modifications that have been made to the wording of this comment, as it appeared in the second CHS notice include: a. The following underlined words have been added: Although efforts were made after Mr Bearham’s suicide attempt to alter the door handle of the specific room in which he made his attempt, nothing was done in relation to other door handles which were of similar design, in the AMHU or MHAU other than the social spine of the AMHU. The method of using a closed door as a ligature attachment point was known to ACT Health before Mr Bearham’s death, and certainly was known after his death. Ms Fisher completed suicide using a similar method of attaching the ligature to the door handle… b. The concluding words of the comment (“and even then, not until there was a risk of TCH losing facility accreditation”) have been re-inserted.
The addition of the words set out in (a) above conflates and materially misstates the evidence, which was as follows: a. Mr Bearham attempted suicide by using the door of a bathroom in the social spine of the AMHU. The handles to that door were removed by staff after the incident. They were shown to police when they attended the AMHU on 7 January 2014.
b. According to the investigating officer, the handles that had been on that particular door were different in design to the ligature safe handles that were used on other doors of the social spine.11 They were conventional lever type door handles.12 After Mr Bearham’s suicide attempt, a critical risk assessment was undertaken by staff and those particular handles were identified as a ligature risk and removed.13 11 SJ Norman XN, 10 April 2018, p 23 at lines 35 to 40.
12 B Duffy XN, 11 April 2018, p 116 at line 45 and p 141 lines 15 to 20.
13 J. Acs XN, 12 April 2018, p 259 at line 1.
c. Ms Plant recalled that there were other bathrooms in the social area of the AMHU with similar door handles. She gave evidence that, after Mr Bearham’s death, all those handles were changed to ones that were compliant with the Australian Facilities Guidelines.14 d. The handles in the consumer’s rooms in the AMHU were different to the lever type handles that had been removed.15 They were anti-ligature handles and compliant with the relevant guidelines and indeed are still in use in mental health facilities.16 e. After Mr Bearham’s death, senior staff undertook a walk-through of both the AMHU and the MHAU to review the doors and handles to ensure that they were anti-ligature and compliant. 17 f. All of the door handles in the MHAU were compliant with the Australian Facilities Guidelines.18 g. There was no evidence that the door handle of the ensuite in which Ms Fisher died was used as a ligature point. Rather, the door was locked and a witness who first attended the scene noted what was likely to be the knotted end of the dressing gown cord over the top of the door.19 That is, she in all likelihood used the closed door, rather than any handle, as the ligature point.
h. After Ms Fisher’s death, the lock on that door was removed and there was consideration given to removing the door of the ensuite bathroom altogether.20 The issue was revisited after the outcome of the CRC review into the death of Ms Fisher (August 2015).21 Due to privacy concerns, the clinical risk represented by retaining the door was (successfully) managed in other ways. 22 Professor Large gave evidence that most ensuites in modern psychiatric units are built with doors.23 i. Ms Plant also gave evidence that, after the death of Mr Bearham and Ms Fisher, consideration was given to retrofitting alarms to doors in the AMHU, but this was deemed to be not feasible.24
15 D Plant XN, 6 September 2018, p 328 at line 10.
16 Professor Large XN, 7 September 2018, p 355 line 40 to p 356 line 10.
17 D Plant XN, 6 September 2018, p 328 at lines 40 to 45, p 335 at line 25 and p 339 at line 20.
18 D Plant XN, 6 September 2018, p 329, at lines 1 to 5; lines 333, lines 1 to 2; Professor Large XN 7 September 2018, p 357 lines 25 to 45.
19 T Sealey statement, CD31, at [6].
20 D Plant XN, 6 September 2018, p 316 lines 23-32, p 332 lines 44-45 and p 333, lines 1-7.
21 See Submissions of 13 November 2018 [227] (g) and the references at footnote 234.
22 Transcript dated 6 September 2018, DA Plant XN, P-316, lines 23-32, 44-45; P-333, lines 1–7.
23 See Submissions of 13 November 2018 [227] (e) and the references at footnote 234.
24 See Submissions of 13 November 2018 [227] (c) and the references at footnote 235.
handles. The handle to the ensuite door used by Mr Lucas did have an anti-ligature design, but Mr Lucas succeeded in using it as a ligature point. After his death, a comprehensive inquiry into door hardware and design was undertaken to mitigate this risk.
After her death, that risk was assessed by senior staff and managed appropriately and successfully.
In the light of this evidence, the Territory repeats submissions that have already been made, that a comment to the effect that the response to ligature risk was “inadequate and belated” is unfair and unreasonable and not supported by the evidence.
As for the second modification to the wording of this comment, the concluding words (“and even then, not until there was a risk of TCH losing facility accreditation”) were included in the draft comment that was contained in the first CHS notice. In its submissions dated 30 September 2020, the Territory set out the reasons why this aspect of the comment was not justified by the evidence. In particular, it was noted that, by the date of the report of the ACSQHC concerning accreditation in March 2018:25 a. an engineer’s report had been obtained in relation to door hardware and design in the Mental Health Inpatient Unit; b. MHJHADS had commissioned an external consultant to undertake a comprehensive risk assessment of all ACT mental health facilities; c. MHJHADS had provided comments on the report of the consultant report; d. There had been a request for infrastructure procurement, giving priority funding to the AMHU; e. the Executive Director of MHJHADS requested removal of all of the ensuite doors in the AMHU in advance of a full ligature risk minimisation project completion; f. the new CHHS clinical procedure relating to ligature risk had been drafted and commenced; and g. even before funding had been approved, work on ligature risk minimisation, including the removal of ensuite doors within the AMHU, was well underway.
Having considered those submissions, the Coroner removed the concluding words from the draft of this comment in the second CHS notice. They have been added back to the most recent version of the comment in the third CHS notice, with no explanation.
25 At [200], the references to the evidence can be found in the Territory’s submissions dated 13 November 2018 at 227 to (t).
V. Thomas 12th Floor Wentworth Chambers 2 March 2021
INQUEST INTO THE DEATHS OF ANTHONY BEARHAM (CD 8 OF 2015) NICOLA FISHER (CD 61 OF 2015) CHRISTINE DOUCH (CD 164 OF 2016) KEN LUCAS (CD 281 OF 2016) ACT CORONERS COURT STATEMENT OF KAREN GRACE PURSUANT TO S 55(1) OF THE CORONERS ACT 1997 (ACT)
I am Executive Director, Mental Health, Justice Health and Alcohol and Drug Services ('MHJHADS').
I make this statement in response to a notice from the Coroner dated 25 Februmy 2021, containing proposed comments in relation to Canberra Health Services that the Coroner proposes to include in her Findings in each of these inquests, which she proposes to publish on 4 March 2021.
I am authorised by the Territ01y and Canberra Health Services to provide a statement pursuant to s 55(1)(b) of the in each of the above inquests.
If and to the extent that the comments included in the notice dated 25 Februmy 2021 are included in the Findings, I request that the Findings also include a statement to the effect set out below.
I make this statement largely on the basis of submissions made by the Australian Capital Territory (the Territory) dated 13 November 2018 (in response to submissions by Counsel Assisting), 30 September 2020 (in response to the firsts 55 notice issued by the Coroner) and 2 March 2021 (in response to the latests 55 notice).
Statement for inclusion in the Findings
facilitate her suicide and Mr Lucas was found to have two bottles of scotch under his mattress.
In the case of Ms Fisher, I find specifically that she should not have been able to retain her dressing gown belt, and the failure by multiple staff to have noticed it and remove it was a contributory factor to her death. It is difficult to understand how it was missed by staff who had been keeping a close observation of her every 30 minutes.
The Territory's submissions noted that the policies relevant to the searching of a consumer's property that were in place at the time of the deaths of Mr Bearham, Ms Fisher and Mr Lucas in respect of voluntaiy patients, were premised on patient consent.1 If that consent is not provided, then there can be no lawful search of the patient or the patient's belongings.
The proposed comment does not identify any specific respect in which any of the policies in place were deficient, nor identify any staff member who was not sufficiently trained in those policies. It appears to be premised on the fact that (in the case of Ms Fisher and Mr Lucas) potentially harmful items were found in the relevant facility after the incident. 2
For the Bearham matter, the basis for this comment is said to be that Mr Bearham had "methamphetamine in his toxicity screen".
I 0. I understand this to be a reference to toxicology results from blood tests taken while Mr Bearham was in the Intensive Care Unit (ICU).
There is no evidential basis for linking the blood results obtained when he was in the ICU to any deficiency in the search procedures or in staff training at the AMHU and no evidence to support the proposed comment insofar as it relates to Mr Bearham.
For the Lucas matter, the basis of this comment is that two empty bottles of alcohol were found under the mattress in his room, after his attempt at self-harm.
I understand that there was no evidence as to how the bottles (which had contained brandy, rather than scotch) were brought into the AMHU. There was evidence that established that there had been a discussion with Mr Lucas in relation to his belongings and clothing when he was admitted to the AMHU3 and no evidence that would support a finding that Mr Lucas brought any alcohol into the unit. The evidence of Mr Lucas' brother and of the medical records was that Mr Lucas did not drink.4 It is possible that the bottles had been left by a previous occupant of Mr Lucas' room. Whether that was 1 See Submissions dated 13 November 2018 at [160] and [161] 2 See Submissions dated 30 September 2020 at [153].
3 CD 15 (Lucas) pp 163 to 164.
4 Transcript of conversation with Ian Lucas, page 15. Patient Health Summary from Watson General Practice, page 1 ("non drinker").
what occurred and whether or not that was linked to any failure to implement the search policy in place at the time was not, as I understand, explored at all in the evidence.
I understand that there was no evidence that the items had any relevance to Mr Lucas' attempt at self harm.
In relation to training, the Territory's submissions referred to evidence that MHJHADS staff received training regarding property removal in the light of a patient's clinical risk. 5 The comment does not identify any specific deficiency in that training.
The Territory considers that, in the case of a unit for voluntary patients, where consent must be provided for searches of person or property, consumers are allowed leave and return to the unit during the course of their admission, and visitors are permitted to enter the unit, it cannot be assumed that any search procedure, no matter how rigorous or well understood by staff, will guarantee that no harmful items will find their way onto the unit.
The Territory accepts that the dressing gown cord used by Ms Fisher as a ligature should have been removed from her for her safety. I understand that all staff who gave evidence in relation to this issue accepted that they would have understood that this was the case at the time. 6 I further understand that the reason why it was not removed between the time of her admission to the Mental Health Assessment Unit (MHAU) and her attempt at self harm was not clearly established on the evidence admitted at the inquest. 7
The notice referred to in [2] above states that the Coroner proposes to include the following comment in her findings: In relation to Ms Fishers treatment, having considered the evidence, in my view it was inappropriate and undesirable for Ms Fisher to have remained on the MHAU for as long as she did without any active psychiatric treatment or comprehensive assessment for suicidality. Having said that, I acknowledge the difficulty of the individual practitioners involved in treating Ms Fisher in relation to bed block at the AMHU and Ms Fisher's refusal to engage with them.
However, I find that the failure to reassess Ms Fisher for suicidality may have been a contributory factor to her death. I note that sh01tly after Ms Fisher's death the Chief Psychiatrist directed that MHAU patients were to be reviewed at least every 24 hours and I commend this change to procedures.
6 See [157] and [172] of the Submissions dated 13 November 2018.
7 See [169] of the Submissions dated 13 November 2018.
8 Statement of Dr Rodrigo, dated 6 July 2015, at [ 15].
9 Statement of Dr Rodrigo, dated 6 July 2015, at [18].
Ms Fisher was not medically reviewed the following day while she was waiting for a bed to become available in the AMHU. The evidence was that, during that day, she spent most of the time in bed and slept a great deal. I understand that there was evidence of observations over the course of that day. None of the staff members who recorded those observations perceived a significant deterioration in her condition.10
In relation to the suggestion that the failure to reassess Ms Fisher "may" have been a factor that contributed to her death, I understand that the only hypothetical that was put to Dr Rodrigo was the making of an involuntaiy detention order in respect of Ms Fisher on 19 March 2015. His unchallenged evidence was that this would not have been appropriate, in his view. In any event, he said that this would not necessarily have allowed Ms Fisher to obtain a bed in the AMHU any earlier. 11
Further, I understand that Dr Rodrigo was not asked how he would have assessed Ms Fisher if he had reviewed her again on 19 March 2015. It was not put to him that this would have led to any course of treatment, or to a transfer to the AMHU or to a search of her belongings, or to any course of action that would have avoided her suicide attempt.
In the circumstances, the Territory does consider that the suggestion that the failure to reassess Ms Fisher may have contributed to her death is speculative and not properly supported by evidence.
As the comment recognises, after Ms Fisher's death, procedures were changed so that a patient in the MHAU was to be medically reviewed at least once every 24 hours.
The MHAU was decommissioned in Januaiy 2016. A new facility, known as the Mental Health Short Stay Unit (MHSSU) was opened. Unlike the MHAU, it is an inpatient facility.
The notice referred to in [2] above states that the Coroner proposes to include the following comment in her findings: In Mr Lucas' case, a staff member failed to properly record his ARC levels and observations of him were carried out less frequently than had been directed by the Consultant Psychiatrist. TCH's systems provided no opportunity to identify or correct the error. While this cannot be said to have been a direct contributing factor to Mr Lucas' death, it provided him with a greater window of opportunity in which to commit self-harm, as well as limiting the opportunity for Mr Lucas to have been discovered mid-act and potentially diverted.
The question of whether the Coroner has power under the Coroners Act to include the proposed comment in her findings was dealt with in the Territmy's submissions dated 30 September 2020 at paragraphs [8]-[29] and [185]-[188]. The Territmy continues to hold the view that the Coroner does not have any such power, for the reasons summarised at paragraphs [185]-[l 88] of those submissions.
The relevant "error", as I understand it, was the performance of hourly rather than half hourly observations of Mr Lucas after his clinical risk was reassessed by Dr Ahlin and 10 See [196] of the Submissions dated 13 November 2018.
11 Transcript dated 1 May 2018, Rodrigo XN, p 35, lines 15-20.
Dr Modak on 11 November 2016. This was an error because Dr Ahlin had assessed Mr Lucas' risk at ARC 2.5, which required half hourly observations. This was appropriately documented but, the evidence would suggest, was not handed over to other members of the nursing staff responsible for performing those observations after Mr Lucas' medical review.
The Territ01y thus does not understand the reference to an individual staff member failing to properly record Mr Lucas' ARC levels.
In November 2016, there was a system in place directed to ensuring that any variation, in particular any increase in the frequency of patient's ARC observations by medical staff would be implemented by nursing staff. The Territ01y does not consider that the system in place at the time can fairly be described as providing "no opportunity" to identify or correct errors such as the one that occurred in the case of Mr Lucas.
In accordance with the system in place at the time of Mr Lucas' admission, any variation in ARC score was required to be noted on a Clinical Risk Re-Assessment form (CRA).
This form was required to be signed by the doctor recommending the increase frequency of observations and co-signed by a nurse, ideally (but not always) being the nurse to whom the patient had been allocated that day.12
Following the completion of the CRA, the system in place during 2016 was that the nurse who had countersigned the CRA was required to show the team leader the CRA and advise him/her of the change as well as the nurse allocated to the patient (ifhe or she had not been the one to countersign the foim).13 In that way, the increased frequency of ARC score observations would not only be implemented on that shift, but also handed over to the next shift.
The Territ01y accepts that, in the case of the increase in the frequency of ARC score observations for Mr Lucas that was directed on 11 November 2016, this system did not operate as intended. As the comment notes, the system has since been changed to further reduce the risk that changes in "at risk" scores will not be appropriately implemented by nursing staff.
The notice referred to in [2] above states that the Coroner proposes to include the following comment in her findings: The response of ACT Health to dealing with issues of ligature risk was inadequate and belated, and represents a systemic failure. Although eff01is were made after Mr Bearham's suicide attempt to alter the door handle of the specific room in which he made his attempt, nothing was done in relation to other door handles which were of similar design, in the AMHU or MHAU other than the social spine of the AMHU. The method of using a closed door as a ligature attachment point was known to ACT Health before Mr Bearham's death, and ce1iainly was known after his death. Ms Fisher completed suicide using a similar method of attaching the ligature to the door handle. Between Ms Fisher's death and Mr Lucas' death, ACT Health did not take any significant active steps to mitigate ligature risk across mental health inpatient facilities until after Mr Lucas' death, and even then, not until there was a risk of TCH losing facility accreditation.
12 Exhibit CD 24, Statement of Ms Nissen, [21] (Lucas).
13 Exhibit CD 24, Statement of Ms Nissen, [22] (Lucas).
The Psychiatric Services Unit was decommissioned in 2012 and was replaced by the AMHU. There had been no deaths as a result of self harm attempts in the AMHU prior to January 2015. I understand that there was expert evidence admitted at the inquest that, as built, it was within the range of acceptable standards of design for contemporary psychiatric wards in Australia.14
The Ten'ito1y does not consider that the comment accurately reflects the evidence that was admitted in the Bearham, Fisher and Lucas inquests (including Phase 2) of the inquests, which included the following: a. Mr Bearham attempted suicide by using the door of a bathroom in the social spine of the AMHU. The handles to that door were removed by staff after the incident. They were shown to police when they attended the AMHU on 7 Januaiy 2014.
b. According to the investigating officer, the handles that had been on that particular door were different in design to the ligature safe handles that were used on other doors of the social spine.15 They were conventional lever type door handles.16 After Mr Bearham's suicide attempt, a critical risk assessment was undertaken by staff and those particular handles were identified as a ligature risk and removed. 17 c. Ms Plant recalled that there were other bathrooms in the social area of the AMHU with similar door handles. She gave evidence that, after Mr Bearham's death, all those handles were changed to ones that were compliant with the Australian Facilities Guidelines.18 d. The handles in the consumer's rooms in the AMHU were different to the lever type handles that had been removed.19 They were anti-ligature handles and compliant with the relevant guidelines and indeed are still in use in mental health facilities. 20 e. After Mr Bearham's death, senior staff undertook a walk-through of both the AMHU and the MHAU to review the doors and handles to ensure that they were anti-ligature and compliant. 21 f. All of the door handles in the MHAU were compliant with the Australian Facilities Guidelines.22 14 Professor Large-see Submissions dated 13 November 2018 at 227.
15 SJ Norman XN, 10 April 2018, p 23 at lines 35 to 40.
16 B Duffy XN, 11 April 2018, p 116 at line 45 and p 141 lines 15 to 20.
17 J. Acs XN, 12 April 2018, p 259 at line 1.
18 D Plant XN, 6 September 2018, p 337 at line 5.
19 D Plant XN, 6 September 2018, p 328 at line 10.
20 Professor Large XN, 7 September 2018, p 355 line 40 top 356 line 10.
21 D Plant XN, 6 September 2018, p 328 at lines 40 to 45, p 335 at line 25 and p 339 at line 20.
22 D Plant XN, 6 September 2018, p 329, at lines 1 to 5; lines 333, lines 1 to 2; Professor Large XN 7 September 2018, p 357 lines 25 to 45.
g. There was no evidence that the door handle of the ensuite in which Ms Fisher died was used as a ligature point. Rather, the door was locked and a witness who first attended the scene noted what was likely to be the knotted end of the dressing gown cord over the top of the door.23 That is, she in all likelihood used the closed door, rather than any handle, as the ligature point.
h. After Ms Fisher's death, the lock on that door was removed and there was consideration given to removing the door of the ensuite bathroom altogether.24 The issue was revisited after the outcome of the Clinical Review Committee (CRC) review into the death of Ms Fisher (August 2015).25 Due to privacy concerns, the clinical risk represented by retaining the door was (successfully) managed in other ways. 26 Professor Large gave evidence that most ensuites in modern psychiatric units are built with doors.27 Ms Plant also gave evidence that, after the death of Mr Bearham and Ms Fisher, 1.
consideration was given to retrofitting alarms to doors in the AMHU, but this was deemed to be not feasible.28 3 7. Thus, while the handles of doors were implicated in the suicides of Mr Bearham and Mr Lucas, it is not correct to say that they were similar designs. The door handle used as a ligature point by Mr Bearham was not ligature proof, as it was in a public area of the AMHU. After his death all such door handles were removed and replaced anti-ligature handles. The handle to the ensuite door used by Mr Lucas did have an anti-ligature design, but Mr Lucas succeeded in using it in his attempt at self harm. After his death, a comprehensive inquhy into door hardware and design was undeiiaken to mitigate this risk.
In relation to Ms Fisher, the evidence pointed to the use of a closed door, rather than a door handle, as a ligature attachment. The room in which she had been placed was the only room in the MHAU with an ensuite. After her death, that ligature risk was assessed by senior staff and managed appropriately.
No specific deficiency has been identified in any of the assessments that occmTed before Mr Lucas' death. Nor does the comment identify any specific measure (such as removing ensuite doors altogether or retrofitting alarms) that, in the view of the Coroner, should or could feasibly have been implemented after the deaths of Mr Bearham or Ms Fisher.
In the light of this evidence, the Territmy does not consider that it can reasonably be said that its response to ligature risk was "inadequate and belated".
The concluding words of the comment convey that ligature risk was only addressed when there was a risk of TCH losing accreditation for its inpatient mental health facilities. The Territmy does not consider that this aspect of the comment is justified by the evidence.
23 T Sealey statement, CD31, at [6].
24 D Plant XN, 6 September 2018, p 316 lines 23-32, p 332 lines 44-45 and p 333, lines 1-7.
25 See Submissions of 13 November 2018 [227] (g) and the references at footnote 234.
26 Transcript dated 6 September 2018, DA Plant XN, P-316, lines 23-32, 44-45; P-333, lines 1-7.
27 See Submissions of 13 November 2018 [227] (e) and the references at footnote 234.
28 See Submissions of 13 November 2018 [227] (c) and the references at footnote 235.
The findings of the Australian Commission on Safety and Quality in Health Care (ACSQHC) were issued in March 2018. The evidence was as follows: a. On 12 November 2016, Mr Lucas attempted self harm on the AMHU and died in ICU five days later. The ligature was fixed to the handle of a door.
b. On 15 November 2016 an audit of all of the doors in the AMHU was undertaken.
The same day the Executive Director of MHJHADS e-mailed a number of staff noting comments and suggestions that had been received over the last few days, being "the first step to review our safety system regarding ligature minimisation in our units". She noted that the overarching aim was to unde1iake "point in time" review of all door hardware and designs in all units.29 c. In December 2016 there was a "walk-through and preliminary risk assessment" unde1iaken by the AMHU management team and Health Infrastructure Services (HIS), to identify the issues relating to door fittings and fixtures. A similar risk assessment was undertaken at the MHSSU.30 d. In January 2017 an engineer's report was finalised as a result of the review, entitled "Part 1 report on Door Hardware and Design in Mental Health Inpatient Unit".31 In relation to the AMHU, the potential for pressure sensors to be used on the bedroom doors was raised. While the bathroom doors were identified as a clinical risk and should be removed, the authors of the repmi noted that approximately half of the ensuite doors were placed at an angle in which there was vision directly through the viewing panel straight into the ensuite ( consistent with the privacy issues noted by MHJHADS after the Bearham and Fisher CRCs). These required an alternative solution. It was also noted that the door handles identified throughout the unit were an increased risk and required replacement. A recommendation was made as to the type of door handle to be used.
e. In relation to the MHSSU, the report also recommended the consideration of pressure sensors being fitted to the bedroom doors. There was no recommendation in relation to the door of the ensuite bathroom in the MHSSU or the door hardware.
f. In April 2017, HIS engaged specialist architects, Silver Thomas Handley to undertake a formal risk assessment within its mental health facilities. Those consultants worked in conjunction with HIS and MHJHADS to provide comments on the report and undertake a risk rating exercise in order to prioritise the recommendations.32 g. The work of the external consultants and a risk rating exercise undertaken by MHJHADS was completed in August 2017. The following month, approval was given by the Business Support and Infrastructure Executive Committee (BSIEC).
29 Documents in response to subpoena of21 August 2018, Vol. 1, CD 1, p. 589.
30 This is referred to in the January 2017 report - MHJHADS review of systems to reduce ligature risk in inpatient mental health units, which is Attachment C to the Statement of Ms Braun, Phase 2, CD 2; see pp.
4, 6.
31 See Attachment C to the Statement of Ms Braun, Phase 2, CD 2.
32 Statement of Ms Braun, Phase 2, CD 2, at [16].
h. On 5 December 2017 there was a request for infrastructure procurement prepared by a Mr Wall of the HIS. The request states that priority for funding was to be allocated to the AMHU.33
Even in the absence of final funding approval, in December 2017, the Executive Director of MHJHADS requested that HIS remove the AMHU ensuite doors in advance of a full ligature risk minimisation project completion. This work began in January 2018. 34 J. At the same time as the investigation of structural changes was proceeding, the drafting of the Canberra Hospital and Health Services clinical procedure entitled "Ligature Use in Inpatient Mental Health Units: Response and Management" 35 commenced in 2017.36 k. Ms Braun said in her evidence that a funding source was identified in relation to the work in March 2018 (around the time of the accreditation review).37 But by that time work on ligature minimisation was already well underway. The work required the closure of patient bedrooms and had to be programmed in a way as to cause minimum disruption to the operations of the AMHU and avoid causing significant impact on bed availability.38 I. The work commenced in January 2018 included the removal of the doors, which involved installing a new stainless-steel plate around the doorframe. It was discovered, however, that this remediation created an unintended fmiher ligature risk that required further consideration. There was discussion and a further solution was found that was then endorsed and the works recommenced on 23 April 2018. 39
The Territory considers that, in view of this evidence, the concluding words of the comment are wholly unwarranted and umeasonable.
Dated 33 Documents in response to subpoena of21 August 2018, Vol. 1, CD 1, pp. 621-622.
34 Statement of Ms Braun, Phase 2, CD 2, at [17]; H Braun XN, 3 September 2018, Transcript, p. 27, lines 41-44.
35 Attachment F to the Statement of Ms Braun, Phase 2, CD 2.
36 H Braun XN, 5 September 2018, Transcript, p. 143, line 11.
37 Statement of Ms Braun, Phase 2, CD 2, at [16].
38 Statement of Ms Braun, Phase 2, CD 2, at [18].
39 H Braun XN, 4 September 2018, Transcript, p. 108, lines 16-27.
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