A Tasmanian coroner has condemned the poor decisions and below standard care at the Royal Hobart Hospital, after a woman who was admitted to a psychiatric unit designed to accommodate low-risk patients hung herself.
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How the woman was able to take her own life, the decisions that led to her admittance, and the systematic failures that contributed to her death were the subject of a coroner's report handed down by Simon Cooper on Thursday.
Mr Cooper pointed to a chaotic lack of governance at the hospital, a lack of team structure and a lack of systematic management of risk as contributing factors to the death of the woman "who was obviously a suicide risk".
On February 17, 2018, the woman's husband contacted the Clarence and Eastern Adult Community Mental Health Service asking for an urgent assessment, as his wife was expressing suicidal ideation.
The CAT team facilitated the woman's transport to the Royal Hobart Hospital, where she was evaluated in the emergency room.
She was then admitted to the open unit of the hospital's psychiatric department as a voluntary patient.
"The decision to accommodate her in the open unit appears to have been made after discussion between a psychiatric registrar and a psychiatric emergency nurse who actually carried out the assessment ...," Coroner Cooper noted.
"Two alternatives to the open unit existed, the high dependency unit and the closed unit. The open unit was designed to accommodate patients in lower-risk categories."
The next day, staff contacted the woman's husband requesting he bring her medication to the hospital, "as a particular prescription was not available in the hospital pharmacy".
On this day the woman was seen by a psychiatric registrar and consultant.
"Her medical records indicate she was assessed as having a 'suicidal crisis'," the report reads.
"Her records indicate she stayed mainly in her room, seemed 'flat' to nursing staff and was noted as being unable to guarantee her safety."
On February 19, nursing staff assessed the woman as having a "moderate risk" of intentional self-harm.
"That assessment is recorded as being made late in the morning of that day," Coroner Cooper noted.
"She was seen by staff in the unit at about 1pm."
However, about 3.10pm the woman was found in the room, having hung herself. She was unconscious and in cardiac arrest.
She was resuscitated, intubated, ventilated, and transferred to the intensive care unit, but here she remained critically unwell.
"She was neurologically unresponsive" and after consultation with her family, ventilator support was withdrawn and she died shortly after.
The focus of the investigation was to determine how the woman, admitted to a psychiatric unit in a hospital because of suicidal ideation, could in fact commit suicide in that unit.
Coroner Cooper noted that at the time of her admission the woman was "extremely mentally unwell".
"That fact should have been apparent at the time of her admission," he said.
"She was receiving a high level of mental health care and support in the community and was evidently in a crisis because of an escalation of her symptoms."
Coroner Cooper said he was satisfied the woman was appropriately assessed when she reached the hospital.
However, he said the decision to admit her to the psychiatry department's open unit "seems to have been the wrong one given the significant change in the pattern of her presentation from previous admissions".
These factors were acknowledged in the hospital's Final Root Cause Analysis Report, which indicated the decision was made in the context of: chaotic lack of governance, nursing processes and structures; a ward that was managed as a single ward, yet was three discrete units geographically separated; a lack of team structure; and a lack of systematic management of risk and operations.
Mr Cooper said he was satisfied all of these factors contributed to decisions which led to the woman being accommodated in the open ward.
"A number of other factors, all unfortunately adverse, contributed to her death," he said.
After the woman was reviewed by a consultant, Mr Cooper said there was no evidence in her medical records that a management plan formulated for her was actually followed.
"This is particularly important because the management plan required hourly observations," he said.
"Had those observations been undertaken, staff may have been given a clue as to her intentions."
Mr Cooper said the woman was also put into a room that allowed her to use a ligature to hang herself.
The door of the room could also be locked from the inside.
"This meant, given the nursing staff did not appear to be carrying a key to the door, that there was a delay in entering her room once the emergency was detected," he said.
Mr Cooper said the fact that the woman had, in her possession, a strap which was able to be used as a ligature "seems to me to be indicative of a failure of basic care for a suicidal psychiatric patient".
He said the decision to accommodated the woman in the open unit was a poor one.
"The care she received after being admitted to that unit was, in my view, significantly below the standard reasonably expected," he said.
Mr Cooper said the draft findings of his report were sent to the responsible agencies for comment, and he appreciated the level of cooperation received from the RHH and Statewide Mental Health Services.
"What is not in doubt, is the failure to follow the one hourly nursing review in the admission plan, an apparent absence of proactive consideration of material on hand in a patient's possession [when admitted for suicidal distress], and a built environment which allowed for hanging," the medical director of Statewide Mental Health Services said in a response.
Mr Cooper also accepted advice from the medical director that since the woman's death, statewide mental health services have been moved to a new and specially planned design within K Block "which feature anti-ligature amenities designed in accordance with contemporary practice in mental health units".
While he did consider it necessary to make any formal recommendations, Mr Cooper commented that the issues highlighted in the report directly contributed to the woman's death.
"It is imperative that they are addressed by the hospital," he said.
- If matters discussed in this article have raised concerns with you, call Lifeline on 13 11 14.
Jessica Willard
Being a health reporter to me is about more than just reporting the problems. It's about asking why they are happening in the first place and what needs to change to fix it.
Being a health reporter to me is about more than just reporting the problems. It's about asking why they are happening in the first place and what needs to change to fix it.
