Coroner asks for changes to processes

At the conclusion of an inquest into the death of a patient at Dubbo Hospital in 2014, Magistrate Teresa OSullivan detailed seven recommendations that will hopefully reduce the risk of high-dependency patients in the mental health unit taking their own lives.

The inquest relates to the circumstances surrounding the death of a patient known only as MA in February 2014.

MA, who was an involuntary inpatient at the Dubbo unit at the time of his passing, died as a result of neck compression consistent with hanging, a consequence of actions taken with the intention of ending his own life.

It raised questions about the reporting of observations on patients in the unit, which had earlier been brought up in an internal investigation into the matter.

Magistrate OSullivan detailed an observation made in the findings of that investigation, where it described endemic failures of clinical practice, procedure and culture in the hospital at the time.

She also praised steps taken subsequent to the incident to deal with nursing engagement.

Since MAs death, there have been significant statewide changes made in the area of nursing engagement and observation of patients in mental health units and that is to be commended, she said in her conclusion.

Among the changes recommended by Magistrate OSullivan is the development of procedures and policies to ensure an appropriate skill mix is available within the nursing staff in mental health units as well as to ensure the identification and communication by all mental health clinical staff of the rationale for the setting and/or changing of patient observation status and levels.

Other processes she recommended be brought into place include the clear identification of the nurse assigned responsibility for the recording of observations and engagement, and the documentation of engagements and observations when they occur in an attempt to avoid the practice of block recording.