Inquest into the death of CCW

STATE CORONER’S COURT OF NEW SOUTH WALES Inquest: Inquest into the death of CCW Hearing dates: 31 May – 1 June 2017 Date of findings: 11 July 2017 Place of findings: State Coroners Court, Glebe Findings of: Magistrate H Barry Catchwords: CORONIAL LAW – suicide risk, observation levels File number: 2015/166846 Representation: Mr C McGorey, Counsel Assisting the Coroner, instructed by Mr P Armstrong Crown Solicitor’s Office.

Mr P Rooney instructed by Ms M Fisicaro for South West Sydney Local Health District.

Mr G Gemmell instructed by Ms D Ashton for Dr Yong Ms T Stevens instructed by Ms K Bowers for Dr Valachova Non publication order: An order under s75 (1) Coroner’s Act prohibiting any publication of any matter that identifies CCW or her relatives including photographic material

Findings: The Coroners Act in s81 (1) requires that when an inquest is held, the coroner must record in writing his or her findings as to various aspects of the death. These are the findings of an inquest into the death of CCW.

I find that CCW died on 3 June 2016 at Bankstown Hospital, Bankstown from Hypoxic Ischaemic Encephalopathy as a result of Hanging. I find the manner of death to be intentionally self-inflicted.

The Coroners Act in s81 (1) requires that when an inquest is held, the coroner must record in writing his or her findings as to various aspects of the death. These are the findings of an inquest into the death of CCW Introduction Mrs CCW was admitted to Bankstown Hospital on 1 June 2015, following deterioration in her mental state.

She was reviewed in the emergency department and then admitted to Banks House, a gazetted, locked, adult psychiatric unit affiliated with the Hospital.

A bed was located in the open wing of Banks house.

In the early hours of 2 June 2015, CCW was found in a sitting position with a cardigan tied around her neck and around a wardrobe handle. She was not breathing and was unresponsive. The ligature was cut and cardio – pulmonary resuscitation was commenced and the medical emergency team called. She regained a pulse after ten minutes and was transferred to intensive care.

On 3 June 2015, she was found to be brain dead and declared deceased at 9.39 am.

The Role of the Coroner The role of the Coroner as set out in s81 of the Coroner’s Act 2009 is to make findings as to:

(a) The identity of the deceased

(b) The date and place of the person’s death

(c) The physical or medical cause of death; and (d)The manner of death; in other words, the circumstances surrounding the death The primary focus of this inquest is the manner of CCW’s death.

The Autopsy An autopsy report was prepared by Dr Jennifer Pokorney, Department of Forensic Medicine, Sydney on 23 July 2015.

Dr Pokorney noted that CCW died on 3 June 2015 at Bankstown Hospital, the cause of death being Hypoxic Ischaemic Encephalopathy with an antecedent cause being hanging.

The Evidence CCW was born in China in 1947 and with her husband immigrated to Australia from Kiangsu, China in mid - 2009.

CCW and her husband lived with their daughter, Ms C.CCW spoke no English but spoke Cantonese and Mandarin.

Prior to her move to Australia, CCW would write and send letters to a deceased Chinese President. After her arrival in Australia, CCW continued to write these letters and asked her daughter to send them for her. Ms C read the letters which she considered made no sense and did not send them.

From 2012 there is documented evidence that CCW was experiencing mental health issues and was reportedly displaying unusual behaviours. These behaviours centred around hostility towards her husband.

She was of the belief that her husband should commit suicide in order to save China and Hong Kong.

CCW was referred to psychiatrists and prescribed medication. During 2013 and 2014 police had been called to CCW’s house on a number of occasions in response to her deteriorating behaviour.

In July 2014, she was scheduled under s22 of the Mental Health Act following police involvement when CCW threatened to kill her husband. She was admitted to Banks House and remained there for three months. Medical records reveal that she “was tangential in thought and was preoccupied with the Chinese Government. She lacked insight and her judgment was poor.” She was of the belief that the Chinese government had twice saved Mr C’s life and she voiced “delusional beliefs that her husband should commit suicide in order to show his gratitude for this” After her discharge, she was “pleasant and cooperative”. Her doctor noted that by February 2015, CCW appeared to be no longer taking her medication.

On 15 June 2015, Ms C called an ambulance and police because of her mother’s deteriorating condition. Her mother had been trying to physically block her husband from attending a heart specialist claiming, “You deserve to die… there’s no point to see the doctor.” At about 11am police and ambulance arrived. Ambulance Officer R Kennedy noted that in response to a question posed by him to CCW and translated by her daughter, CCW indicated that she wanted to kill herself and had had a plan to do it earlier that morning.

CCW was admitted to the Emergency Department in Bankstown Hospital where she remained with her daughter in a locked area with staff members assigned to observe her.

Clinical Nurse Consultant Bodiuz Zaman attended CCW in the Emergency Department and requested the attendance of Dr Yong, Psychiatric Registrar.

Dr Yong conducted a preliminary assessment at 2.30pm and spoke to CCW in Cantonese without the need for an interpreter.

Following that assessment, Dr Yong spoke to his supervisor, Dr Iveta Valachova, a Consultant Psychiatrist working as a Geriatric Psychiatrist in the Psychogeriatric Unit.

Both doctors then conducted an assessment of CCW with Dr Yong translating questions posed by Dr Valachova.

The assessment of CCW and the management plan.

Dr Yong Dr Yong assessed CCW to be having a relapse of a psychotic illness involving threats to kill her husband. He read the note from the ambulance officer concerning a threat by CCW to commit suicide, but the details were vague and CCW refused to disclose a plan.

Dr Yong expressly questioned CCW about suicide intent and she denied all questions of suicide intent including specific questions put to her regarding possible methods, including hanging.

She clarified she would starve herself to death if she was admitted to hospital.

According to Dr Yong’s evidence she was not making much sense. His main concern was the homicide risk to her husband. He viewed her expression to starve herself as an expression of not wanting to be in hospital.

Her delusional beliefs were that her husband needed to die. Her denials of self- harm were consistent with her delusional beliefs and she was adamant that there was no need for her to die.

In his assessment, CCW’s symptoms were typical of a relapse and his main concern was that she might try to abscond.

Dr Valachova Dr Valachova acknowledged that her memory of what was said to CCW at the time was vague. She did however recall impressions of CCW.

It was her assessment made after posing questions to CCW and having them translated by Dr Yong that CCW was experiencing a relapse of a psychotic illness, most likely schizophrenia. CCW had no suicidal thoughts and had not been taking her medication.

Dr Valachova stated she would have asked CCW if she had any plans to self- harm.

This was confirmed by Dr Yong. She recalls CCW stating she would starve herself because she did not want to be in hospital.

Dr Valachova stated that she could not rely on CCW’s statements. She was too preoccupied with her delusional beliefs and her presentation was “unpredictable”, meaning that the doctor could not get enough understanding of CCW’s condition in the Emergency Department assessment, except to note she was very unwell.

Management Plan Both Dr Yong and Dr Valachova agreed that Ms Wong needed to be admitted to Banks House.

Banks House is located within the grounds of Bankstown Hospital. The mental health unit is a 30 bed acute inpatient mental health unit. The unit is a gazetted mental health facility under the Mental Health Act, which permits persons involuntarily admitted under the act to be detained there for treatment.

The unit is a” locked “area and comprises 2 sections.

One section is known as the “observation area” and contains 10 beds. It has an open observation area, with beds divided into 2 dormitories located on either side of the wing.

The other section is the” open area” or “open side” and contains 20 beds. Those beds are divided between 10 bedrooms, some rooms are for single occupants, others contain multiple occupants.

Both sides of the unit are locked.

The management plan indicated that CCW was to be admitted to the observation area of the unit.

Dr Yong and Dr Valachova stated this was for 2 main reasons: (1) the risk of absconding and (2) the threat to starve herself Dr Valachova also believed CCW needed to be in the observation area because of her floridly psychotic presentation and because of the unpredictable nature of her presentation. She further stated: “There is a limit as to how extensive an assessment can be done the Emergency Department.” In Dr Yong’s opinion CCW did not present as being highly changeable and he stated that her presentation was not typical of a highly changeable state but rather she was

becoming more unwell. He explained:” if she is consistently deteriorating then she is not changeable.” Dr Yong completed a Mental Health Assessment (known as a MHOAT form).

In that form he recorded under the initial management plan: “BH obs – abscond risk – threatening to starve self” Dr Valachova completed a Form 1’pursuant to section 27 of the Mental Health Act.

Her conclusion on that form states: “CCW presents with an acute exacerbation of psychotic illness and requires hospital treatment for the protection of her husband from harm.” Dr Yong’s understanding of the observation area included a level of supervision, being 30 minute observations. He stated that “generally in the observation area a patient is under more observation than in the open area.” He further stated that his understanding was that the observation area is usually used to contain younger patients exhibiting behavioural disturbances and is essentially reserved for persons under the age of 65.

Dr Valachova stated that it was her understanding persons in the observation area of Banks House would be subject to “continual visual observation”. The difference with the open area where she believed observations were made every 30 minutes was that although that area was locked it was easier to come and go from that area and therefore there was a greater opportunity for someone to abscond.

At the time the South West Sydney Local Health District (SWSLHD) had a policy called “Observation Levels”. Four types of observation levels existed within that document. There was no mention of the frequency of observation to be observed in the “observation area”.

A new policy, prepared in June 2015 expressly states that persons admitted to the observation area” or “high dependency unit” are to be initially placed on observation level two, meaning 30 minute observations.

There is no doubt that Dr Valachova was mistaken in her belief that the level of observation in the observation unit meant “continual visual observation” even at night. She later conceded her mistake and stated that she may have been referring to the common area within that unit.

In addition to admitting CCW to the observation unit in Banks House, the management plan included increasing her medication (Quetiapine) to manage her psychotic symptoms.

Also, her food and fluid intake was to be monitored given her threats to starve herself.

Both Dr Yong and Dr Valachova believed CCW’s suicide risk to be low. Dr Valachova made no reference to the suicide risk in the Form 1.

The admission to the open side of Banks House.

CCW was admitted to Banks House at about 5 pm on 1 June 2015. She was admitted to the open area, as there were no female beds available in the observation area of the unit.

When it became clear that no bed was available, Nurse Zaman had contacted Dr Yong and advised him that no bed was available in the observation area and queried if CCW could be admitted to the open side.

She was placed in a single room with a bed, desk and chair and wardrobe. She was the sole occupant of the room which faced into the hallway. She was subject to checks at a 30 minute interval and given food and drink according to the management plan.

Dr Yong stated there was a discussion with Nurse Zaman about the level of risk and he has no recollection of any discussion about a nurse special or 1:1 observation. It was Dr Yong’s view that there was no acute risk of suicide that required observation on a 1:1 basis.

In his opinion, management of CCW could be achieved in the open side, it being a locked ward and the main concerns were her risk of absconding and her homicidal ideation which was directed solely at her husband. He considered that the open side to be the least restrictive option.

Dr Valachova was not aware that CCW had been admitted to the open side of Banks House. In her oral evidence she stated that had she been consulted she would have ordered that CCW remain in the Emergency Department with a special nurse until a bed became available, or ordered a nurse special in the open side. She further stated this was her common practice and noted that open area patients are not usually actively psychotic as was CCW.

In relation to the question as to whether Dr Yong should have consulted her, she stated that she relied on Dr Yong’s judgement, noting he would usually make very good judgments. However, she confirmed she would not have approved the change in plan and would have ordered 1:1 nursing. Dr Valachova acknowledged that this evidence was of course given with the benefit of hindsight.

The Experts Three experts provided reports to the court and gave oral evidence.

• Associate Professor Michael Robertson

• Professor Matthew Large

• Associate Professor Christopher Ryan

All experts were in agreement that the assessment conducted firstly by Dr Yong and secondly by Dr Yong in consultation with Dr Valachova, a senior colleague, was appropriate as was the decision to admit CCW.

Professor Large stated Dr Yong assessed CCW for an adequate period of time and made a correct diagnosis, giving appropriate weight to CCW’s history and the current events.

Neither Professor Large nor Associate Professor Ryan would have considered admitting CCW to the observation area, both expressing concerns about the difficulty in behaviour of patients in that unit, often being young males who are aggressive with acute behavioural disturbance. Both agreed that an observation level of 30 minutes was reasonable in the circumstances.

Associate Professor Robertson’s opinion varied to the extent that he had some concerns about the question of vigilance and observation of CCW and believed that there was a requirement for a higher level of vigilance: “something greater than 30 minute intervals, although he was not ”wedded to 1:1” None of the experts disagreed with Dr Yong and Valachova’s assessment that the risk of suicide was low and both Associate Professor Ryan and Professor Large maintained there was no reasonable choice other than CCW be placed in an open ward.

Professor Large did not accept that it was appropriate to leave a patient in an Emergency Department awaiting a bed.

None of the experts would have considered a 1:1 nurse special, especially in light of the fact that there was no evidence of previous suicide attempts and there was no specific information regarding CCW wishing to self-harm, other than by starving herself.

Comments of self -harm by way of starvation are not unusual statements made by psychiatric patients in hospital, according to the experts, and all experts agreed that the plan to monitor her food and fluid intake was appropriate in order to address this issue.

On the question of whether Dr Yong should have consulted with Dr Valachova about the change in plan, Professor Large stated that although it may have been “polite and nice” for the Registrar to advise the Consultant of the change, he stated that Dr Yong was appropriately qualified to make the call and that decisions made by Senior Registrars in consultation with nursing staff are very reliable.

Associate Professor Ryan said that Dr Yong should have spoken to Dr Valachova about the change of plan as this would have led to “further discussion”.

Associate Professor Robertson said that if there was a change in management plan then a trainee Registrar should always confer with the supervising Consultant.

This difference of opinion concerning the lack of consultation must be viewed in the overall context of the prevailing conditions. Dr Yong spoke with Nurse Zaman and it was clear that there was no bed available in the observation area. CCW needed to be admitted to Hospital. Whilst it may have been more appropriate that Dr Yong consult with Dr Valachova about the proposed change in plan, I am not critical of his failure to do so, given the circumstances at the time and the high regard in which Dr Valachova held Dr Yong.

Conclusion I accept that no criticism should be levelled at either Dr Yong or Dr Valachova.

The evidence supports that the assessment of CCW was appropriate and in accord with good professional practice.

Regrettably CCW was not accommodated in the observation area but it is now clear that she would not have been under constant supervision in that section either. It may be argued that being in a dormitory may have impeded the opportunity to take her life but it is noted that CCW took this action between 1:30 am and 2 am and it is accepted that even in the observation area she may well not have been under close observation during those hours.

There was no evidence to suggest a higher level of vigilance was warranted, especially given her past history of fixation on her husband and not on self- harm.

It is noted that following CCW’s death the Mental Health Service conducted an audit of all ligature and self-harm related risks in the inpatient Mental Health Units of South West Sydney Local Health District. As a result of that audit, all of the door hardware in patient access areas across all inpatient Mental Health Units have been changed to anti-ligature door hardware.

There was considerable discussion by the Experts about appropriate policies especially concerning the issue of observation.

Associate Professor Robertson argued that there is a need for guidelines to be available on this question, more than simply vague expressions of policy. However, he agreed with Associate Professor Ryan and Professor Large that the use of a specialist’s clinical expertise and judgement should not be hampered by overly prescriptive policy documents.

Perhaps the most appropriate and effective intervention to assist in the prevention of such a tragedy in the future comes from evidence provided by Associate Professor Ryan.

Professor Ryan referred to technology titled ‘back- to –base pulse oximetry’.This technology centres around the use or real time back-to-base monitoring that measures pulse oximetry (blood oxygen saturation).These monitors are wireless and can be worn on the wrist of patients.

The advantage of these monitors is that they are less intrusive and allow for continuous monitoring of a person’s oxygen level. If the oxygen was to drop below a certain level (or if the monitor was removed or if the patient moved outside reception range) an alarm would activate, alerting nursing staff, prompting a rapid and possibly life- saving response.

There were no submissions in relation to this technology which is still in the trial stage. However, given the enormous potential of these devices to save lives, I intend to forward a copy of these findings to the Minister for Health for consideration as to how best this information and technology can be utilised by Local Health Districts.

Formal Findings I find that CCW died on 3 June 2016 at Bankstown Hospital, Bankstown from Hypoxic Ischaemic Encephalopathy as a result of Hanging. I find the manner of death to be intentionally self-inflicted.

I offer my sincere condolences to CCW’s family