Inquest into the deaths of ANTHONY LEIGH BEARHAM, NICOLA JOY FISHER, CHRISTINE BELLE DOUCH and KEN ALEXANDER LUCAS
[2021] ACTCD 1
•04 March 2021
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 506Onuma v The Coroner’s Court of South Australia [2001] SASC 218
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 2016CORONER HUNTER Introduction 1. 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.
2. 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).
3. 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.
4. 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.
5. 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.
6. 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.
7. 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.8. 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.
9. I have already made preliminary findings as to the manner and cause of each of the deceased.
Preliminary Matters
Jurisdiction
10. I have reviewed Counsel Assisting’s submissions as to Jurisdiction and have set them
out below as they accord with my own view of the law applicable relating to these
Inquests.
(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.’ “
11. In Lucas-Smith v Ors SC 117 of 2007 Higgins CJ siting the full court in The Queen v Coroner Maria Doogan; ex parte Peter Lucas-Smith & Ors [2005] ACTSC 74; (2006) 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.”
12. In relation to findings of fact, in Saraf v Johns [2008] SASC 166(18) The Court said that;
“the cause of death is a question of fact that must, like causation in the common
law, be determined by the application of ordinary common sense and
experience”
Referring also to March v E & MH Stramare Pty Ltd [1991] 17 CLR 506 for a similar statement as to how the establishment of facts should be drawn.
Section 55
13. 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.
14. In considering and/or making adverse findings the Briginshaw principles are particularly relevant.
15. 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
16. I made interim findings in relation to Mr Bearham’s death on 12 April 2018 in the
following terms;
Anthony Leigh Robert Bearham born 30 December 1989, died on 6 January 2015, at 15:41 hours at The Canberra Hospital, Garran, aged 26 years. Cause of death was hypoxic brain injury caused by attempting to hang himself from the door of a toilet in the Social Spine of the Adult Mental Health Unit (AMHU) at The Canberra Hospital on 4 January 2015 between 23:00 hours and 23:46 hours.
History
17. 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)
18. 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.
19. 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.
20. 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 Preston- Bond 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.
21. 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.
22. 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.
23. 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.
24. 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
25. I made interim findings in relation to Ms Fisher’s death on 2 May 2018 in the following
terms;
Nicola Joy Fisher was born on 8 December 1966 and died on 20 March 2015 at a point approximately between 08:40 hours and 09:43 hours. Ms Fisher was 49 years of age. 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
26. Ms Fisher was born in Ipswich, Queensland but resided in Canberra from a young age. 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.
27. 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).
28. 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.”
29. 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.
30. 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.
31. 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.
32. 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.
33. 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.
34. 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.
35. 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.
36. During the rest of the day RNs tried to engage with Ms Fisher with little success and she continued to refuse fluids and food.
37. 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.
38. 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.39. 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.
40. 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.41. 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.
42. 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.
43. 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.
44. 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.
45. 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.
46. 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.
47. 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.
48. Miss Fisher was identified by her sister Rosemary. Police found no evidence of any third-party involvement or suspicious circumstances in her death.
49. 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.
50. That issue will be one of the issues I will consider in due course.
Christine Belle Douch
51. I made interim findings in relation to Ms Douch’s death on 6 July 2016 in the following
terms;
Christine Belle Douch (born 8 July 1956) died on 6 July 2016 at 02.40 hours from haemothorax and severe blunt chest injuries due to intentionally falling from the third floor onto the second-floor atrium of The Canberra Hospital, Garran on 5 July 2016 at 21.36 hours.
History
52. 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.
53. 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.
54. 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.
55. 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.
56. 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.
57. 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.
58. 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.59. 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 self- harming on a daily basis and those feelings were persistent.
60. 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).
61. 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.
62. 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.
63. 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.
64. 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.
65. 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.
66. 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.
67. 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.
68. 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.
69. 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.
70. 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.
71. 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.
72. 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.
73. 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.
74. 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.
75. 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.
76. 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.
77. 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.
78. 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.
79. 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.
80. 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.
81. 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
82. 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
83. 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.
84. 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.
85. 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.
86. 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.
87. 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.
88. Between 2012 and 2016 Mr Lucas obtain some employment but did not stay in the same job for extended periods.
89. 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.
90. 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.91. 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.92. 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.93. 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.
94. 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.
95. 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.
96. 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.
97. 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.
98. 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.
99. 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.
100. 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.
101. 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.
102. 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.
103. 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 Norman104. 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.
105. 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 ICU.
106. Dr Kumar advised that Mr Bearham had multiple scars, some recently inflicted with what appeared to be a sharp object.
107. 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.
108. 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.
109. 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.
110. 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.
111. 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.
112. 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.
113. 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.
114. 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.
115. 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.
116. 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.
117. 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.
118. 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.
119. 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.
120. 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.
121. Constable Norman requested statements from persons who were involved in that Met call and ultimately those statements were provided.
122. 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.
123. 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.
124. 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.
125. 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.
126. 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). 3 Transcript of proceedings dated 10 April 2018 (p 40). 4 Transcript of proceedings dated 10 April 2018 (p 60.33).
127. 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]
[3] Fisher, Exhibit CD2 – witness statement of Deanne Jewel Best dated 14 August 2015 (Best), [26].
128. 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.
129. 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.
130. 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.
131. 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.
132. 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.
133. 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.
134. 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.
135. 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.
136. 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.
137. Constable Norman argued that to some extent this should be applicable to the ACT mental health setting as well.
138. 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.
139. 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.
140. Constable Norman agreed that when he spoke to Ms Furner, she told him that all items of property would be transferred with the patient.
141. 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.
142. 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.
143. 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.
144. 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.
145. 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.
146. 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.
147. 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.
148. 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.
149. 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.
150. 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.
151. 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.
152. Constable Norman opined that
“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]
[4] Transcript 20.4.18, p 59, ll 40-44; Fisher, Best, [25].
Richard Gray
153. 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.
154. 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.
155. 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.
156. 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.
157. 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.
158. 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.
159. 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.
160. 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.
161. 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.
162. 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.
163. 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.
164. Dr Gray said the lack of resources, lack of staff (particularly on weekends) and the high stress environment made for a difficult working environment.
Bernadette Duffy
165. 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.166. RN Duffy commence working for The Canberra Hospital in January 2007, at that point she had no mental health RN training.
167. 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.
168. 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.
169. 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.
170. 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.
171. 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
35. 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.
36. 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.
37. 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.
38. 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”.
39. 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.
RESPONSE TO LIGATURE RISK
40. The latest notice includes a comment worded as follows:
The response of ACT Health to dealing with issues of ligature risk was inadequate and belated, and represents 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 of the AMHU. The method of using a closed
10 See [178] to [181].
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.
41. 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.
42. 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.
43. 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.
44. 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
45. Thus, while the evidence implicated door handles in the suicide attempts of both Mr Bearham and Mr Lucas, the handles were not of a similar design. 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
14 D Plant XN, 6 September 2018, p 337 at line 5.
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.
46. In relation to Ms Fisher, the evidence suggested that the use of a closed door as a ligature attachment. The room in which she had been placed was the only room in the MHAU. After her death, that risk was assessed by senior staff and managed appropriately and successfully.
47. 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.
48. 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.
49. 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](l) to (t).
50. For reasons that have been addressed in the earlier submissions referred to above, they are not justified by the evidence.
V. Thomas
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)
1. I am Executive Director, Mental Health, Justice Health and Alcohol and Drug Services ('MHJHADS').
2. 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.
3. 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.
4. 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.
5. 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
6. The notice referred to in [2] above states that the Coroner proposes to include the following comment in her findings:
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 Bearl1am, 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 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.
7. 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.
8. 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
Mr Lucas) potentially harmful items were found in the relevant facility after the incident. 2 in those policies. It appears to be premised on the fact that (in the case of Ms Fisher and 9. 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).11.
There was, I understand, no basis on which these results could 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 Adult Mental Health Unit (AMHU) on 2 Januaiy 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.
12. 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. 13.
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.14. I understand that there was no evidence that the items had any relevance to Mr Lucas' attempt at self harm.
15. 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.
16. 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.
17. 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 18. 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.
19. Ms Fisher underwent an initial psychiatric assessment on her first day in the MHAU on 18 March 2015. I understand that Dr Rodrigo, who performed that assessment, did not consider that she was at imminent risk of suicide. 8 In relation to treatment, he directed that she continue with her current antidepressant medication.9
5 See Submissions dated 13 November 2018 at [170].
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].20. 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
21. 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
22. 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.
23. 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.
24. 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.
25. 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.
26. 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
the opportunity for Mr Lucas to have been discovered mid-act and potentially diverted. him with a greater window of opportunity in which to commit self-harm, as well as limiting
27. 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.
28. 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.
29. The Territ01y thus does not understand the reference to an individual staff member failing to properly record Mr Lucas' ARC levels.
30. 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.
31. 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 whom the patient had been allocated that day. 12 of observations and co-signed by a nurse, ideally (but not always) being the nurse to
32. 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
not been the one to countersign the foim). 13 In that way, the increased frequency of ARC advise him/her of the change as well as the nurse allocated to the patient (ifhe or she had score observations would not only be implemented on that shift, but also handed over to
the next shift.33. 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.
34. 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.
13 Exhibit CD 24, Statement of Ms Nissen, [22] (Lucas). 12 Exhibit CD 24, Statement of Ms Nissen, [21] (Lucas).
35.
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
36.
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
15 SJ Norman XN, 10 April 2018, p 23 at lines 35 to 40. 14 Professor Large-see Submissions dated 13 November 2018 at [227](a). 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 7September 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 managed in other ways. 26 Professor Large gave evidence that most ensuites in concerns, the clinical risk represented by retaining the door was (successfully)
modern psychiatric units are built with doors.27
1. 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. 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.
38.
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.
39.
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. 40.
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".
41.
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.
26 Transcript dated 6 September 2018, DA Plant XN, P-316, lines 23-32, 44-45; P-333, lines 1-7. 25 See Submissions of 13 November 2018 [227] (g) and the references at footnote 234. 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 assessment was undertaken at the MHSSU.30 (HIS), to identify the issues relating to door fittings and fixtures. A similar risk 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
recommendations.32 on the report and undertake a risk rating exercise in order to prioritise the 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
1. 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
42. 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.
belt from to commit suicide – (See Exhibit 24 AA [p 10]).[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].
[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 thecontents 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.[12]th Floor Wentworth Chambers
2 March 2021
3
5
1