IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2012 5456

FINDING INTO DEATH WITH INQUEST

Form 37 Rule 60(1) Section 67 of the Coroners Act 2008

Inquest into the Death of: Jarrod Wade Christie

Delivered On: 30 October 2015 | Delivered At: Coroners Court of Victoria | 65 Kavanagh Street Southbank Melbourne 3006 Hearing Dates: Directions: 10 February 2015 |

Inquest: 21 & 22 April 2015

Findings of: Coroner Caitlin English

Representation: , Ms T. Riddell on behalf of Eastern Health ‘ Mr P. Halley on behalf of Dr Chiew

' Counsel Assisting the Coroner: Sergeant David Dimsey

I, Caitlin English, Coroner, having investigated the death of Jarrod Wade Christie

and having held an inquest in relation to his death on 21 & 22 April 2015

at Melbourne

find that the identity of the deceased was Jarrod Wade Christie born on 17 October 1989 and the death occurred on 22 December 2012

at train tracks, Heatherdale Railway Station

from:

1 (a) INJURIES SUSTAINED WHEN STRUCK BY TRAIN

in the following circumstances:

Introduction

L.

On 22 December 2012, Jarrod Christie absconded from Maroondah Hospital high dependency unit where he was an involuntary patient pursuant to s 10 Mental Health Act (1986). He made his way to Heatherdale Train station and leapt in front of a moving train at

approximately 6.37pm. Mr Christie died on the train tracks from injuries he sustained.

An inquest was held into Mr Christie’s death on 21 and 22 April 2015. Eight witnesses gave evidence.

The main issues explored at inquest concerned the circumstances of Mr Christie’s death, particularly his mental health care by his GP, Dr Kim Chiew and Maroondah Hospital, and

when he absconded from Maroondah Hospital on 22 December 2012.

Background

4. Mr Christie was 23 years of age at the time of his death. He resided at 2 Butterfly Gardens,

Doncaster East, with his mother, Mrs Tarnya Garner and stepfather, Mr Kim Garner. Mr Christie’s father, Mr Chris Christie resides in South Aftica. Mr Christie had an older sister, Bianca Christie.

Mr Christic was born in Johannesburg, South Africa. He experienced trauma during his

childhood with his parents separating when he was 18 months old. Mr Christie lived with his

mother who re-partnered and was in a relationship marked by violence for 10 years. Two

years after this relationship ended his mother met Mr Garner, whom she later married.

6. The family immigrated to Australia when Mr Christie was 19. He struggled with the

transition,

7. Mr Christie completed a hospitality course in Melbourne and subsequently worked as an assistant chef for two and a half months. Whilst working as a chef he met his fiancé, Yi Mun Cho. He had interests including Kung Fu and Tai Chi. At the time of his death he was

unemployed.

Reportable Death

8. Mr Christie’s death is a reportable death pursuant to the Coroners Act 2008 (Vic) as it is a _ death that appears to have been ‘unexpected, unnatural or violent or to have resulted directly

or indirectly from an accident or injury’ | Mandatory Inquest

9, As Mr Christie was an involuntary patient pursuant to the Mental Health Act 1986, he was ‘in care’ at the time of his death. As such, an inquest is mandated by section 57(2) Coroners

Aci 2008 (Vic).

Focus of the Inquest

10. The purpose of a coronial investigation is to ascertain if possible, the identity of the

deceased, the medical cause of death and the circumstances in which the death oceurred.

11. In this case, identity and cause of death are not in issue.

12. The inquest focused on the circumstances in which Mr Christie’s death occurred.

13. The circumstances refer to the context of background and events proximate to the death. It is confined to circumstances that are sufficiently proximate and causally relevant, which means there should be a proper connection between the inquiry and the death. Whilst the inquiry is not confined only to matters of strict causation, neither docs it extend to include all

circumstances, which might be part of the narrative culminating in death. 7

! Section 4(2) ? Thales Australia Limited v Thé Coroners Court of Victoria and Anor [2011] VSC 133 (11 April 2011).

14. Correspondence from Mrs Garner received on 7 February 2013 and 12 October 2013 raised a number of concerns regarding the medical care provided to Mr Christie. Mr and Mrs Garner also made a 12 page statement dated 10 June 2013 which is part of the coronial brief. Mrs Garner also provided a list of questions by email dated 17 April 2015-which were put by

Sergeant Dimsey to witnesses during the course of the inquest.

15, The three main issues considered at inquest were:

e Dr Chiew’s prescribing of Pristiq and what impact this had on the deterioration of Mr Christie’s mental health and death;

e Mr Christie’s health care at Maroondah Hospital; and ¢ The accuracy of nursing staff observations and when Mr Christie absconded from the high dependency unit.

Sources of Evidence

16. The evidence in this case is from the coronial brief, the witnesses who were called at the

inquest and the tendered exhibits.

17. The witnesses were Mr Christie’s treating general practitioner, Dr Chiew, Maroondah Hospital consultant psychiatrist, Dr Rehman, nursing staff, Ms Saini, Mr Reed and Mr Williams and the nurse unit manager, Ms Siddall. Mrs Helen Bedggood, who sighted a man resembling Mr Christie near her house shortly prior to his death, also gave evidence, as did

the police officer Constable Grey, to whom she reported her observations.

18. The court also heard from Mr Christie’s sister, Ms Bianca Christie, who made a submission

at the conclusion of the evidence.

Cause of Death

19. Dr Matthew Lynch, Forensic Pathologist at the Victorian Institute of Forensic Medicine conducted an inspection and report on 24 December 2012. Dr Lynch determined the cause of death as ‘injuries sustained when struck by train.’ I accept his opinion.

Health History

20. Mr Christie suffered from scoliosis as a child but was otherwise medically well. He was a

non-smoker and abstinent from alcohol and illicit drugs.

21. His mental health history included long standing issues with depression and anxiety. He was diagnosed with Attention Deficit Hyperactive Disorder as a child and was prescribed psycho stimulants (Methylphenidate) for a period of 12 months when he was 8 years old.

22. Mr Christie’s first contacted Dr Chiew on 3 October 2012 about his mental health issues. He had a rapid deterioration in his mental health, with admission to Maroondah Hospital on a voluntary basis on 15 December 2012 and his death on 22 December 2012. Prior to his admission to Maroondah Hospital, he saw Dr Chiew four times and psychiatrist Dr Lyn-May Lim twice. Dr Lim noted his visit to her on 29 November 2012 was his first visit to a

psychiatrist. He also had a number of sessions with psychologists.

23. Dr Lim noted that Mr Christie stated he had last felt ‘well’ in his early teens and he felt there

had been a ‘gradual decline in his mental state over the last ten years.’ * Impact of Pristiq on Mr Christic’s Deteriorating Mental Condition

24, Mr and Mrs Garner reported a change in Mr Christie’s behaviour from approximately 2010.

He appeared to have difficulty coping with life and sought assistance from a range of

alternative therapies.

25. The family described an incident in October 2012 when Mr Christie ‘went ballistic’ at home, being violent, and damaging property. This was described as out of character and ‘...the first

time Jarrod has ever lost his temper at that level.’ *

26. Following this, on 3 October 2012, Mr Christic saw general practitioner, Dr Kim Chiew at Templestowe District Medical Centre. Mr Christie also saw Dr Chiew on 4 November, 9

November and 14 December 2012. °

27, On 3 October 2012, Dr Chiew completed a mental health plan for Mr Christie and diagnosed him with depression and an anger management problem.® He was initially referred for psychological counselling with Mr Douglas Wright then changed, at his request, to Dr

Jennifer Henson.

3 Coronial brief, p 167.

4 Coronial brief, Statement of Kim & Tarnya Garner p 4.

5 The length of the consultations are as follows: 50 minutes on 3 October, 36 minutes on 9 November, 28 minutes on 14 November and 23 minutes on 14 December 2012. Coronial brief p 144.

6 Letter of Dr Kim Ing Sing Chiew, 12 November 2014, 1.

28. On next review, 9 November 2012, Mr Christie reported no improvement. Dr Chiew prescribed Pristiq ’ 50mg (28 tablets with no repeat) and made a referral to psychiatrist Dr Lyn-May Lim at the same time.

29. Mr Christie saw Dr Lim on 29 November and 5 December 2012.

30. After 13 days, Mr Christie ceased taking Pristiq because of the side effects, however he then felt worse so re-started Pristiq. His parents stated that; “Jarrod wus in a real dark place, suicidal thoughts were really bothering him. Tarnya told Jarrod to come off Pristig because the suicidal side effects were far tofa] damaging. Jarrod came off the medication and was

fine for two days.”®

pare

. Mr Christie had re-started Pristig for five days when he saw Dr Chiew on 14 December 2012.

32. With respect to that consultation Dr Chiew stated:

“Jarrod said he stopped Pristig after 13 days due to “misunderstanding” (about the side effects), and that he had restarted Pristig after a 5 days’ break. He did not report persistent side effects from Pristig. I therefore advised him that if he did not have side effects from Pristig, to continue taking it until the psyhiatrist’s appointment, He was also advised to take

an extra Ativan tablet if he felt more anxious, ’?

33. Dr Chiew gave evidence regarding her diagnosis and treatment of Mr Christie and her

prescribing decisions.

34, As noted above, at his second appointment, 9 November 2012, Dr Chiew diagnosed depression and prescribed Pristiq. She also referred him to psychiatrist, Dr May Lim. Dr Chiew’s evidence was that she informed Mr Christie of common side effects of the antidepressant, namely; nausea, light headedness and agitation. She stated it was her practice when advising patients about the side effects of anti-depressants, not to use the word.

‘suicide’ but rather ‘agitation’.

35. The reason she gave for this was so as not to put patients off making a decision. She stated:

T do not usually mention it because if I tell patients all the side-effects and the information

the patients usually end up not taking tablets because they just- they can’t decide, At this

7 Pristiq is an anti-depressant in a group of drugs called Selective Serotonin and Norepinephrine Reuptake Inhibitors (SNRI). It is used to treat major depression.

8 Coronial brief, Statement of Kim & Tarnya Gamer pp 6-7.

? Letter of Dr Kim Ing Sing Chiew, 12 November 2014, 1,

37,

39,

stage he can’t decide for himself what’s, you know, what he should do. And I usually inform the patients the common side-effects that I also let the patient know, if you experience sideeffects, I will see you as soon as possible. And even if it’s after two or three days a week,

please come back and we’ll discuss the side-effect.’""

Mr Christie’s mother believes that Mr Christie had a telephone conversation between his second and third consultation with Dr Chiew and told her he had suicidal thoughts. Dr Chiew’s evidence was that she did not recall such a call and, if it had happened, there would be a note of it in Mr Christie’s medical records. Further, Mrs Garner believes Dr Chiew stated to Mr Christie, ‘not to worry’ about the suicidal thoughts. Dr Chiew stated she never said that and, if Mr Christie had expressed suicidal thoughts, she would have asked him to

attend for an immediate consultation.

Dr Chiew’s evidence was that on 14 November 2012, Mr Christie reported a number of side effects which she listed in her notes;!! diarrhoea, light headedness, loss of libido, increased anxicty and lots of rapid thoughts. She states he did not report experiencing increased suicidal thoughts, and if he had, she would have taken a particular course of action, namely a

full suicide assessment.

On 11 December 2012, Dr Lim faxed her report to Dr Chiew. She recommended Mr Christie

trial an SSRI anti-depressant such as Escitalopram rather than Desvenlafaxine, due to the significant side effects he had developed and continue the short term use of a

Benzodiazepine.

Dr Chiew concedes she did not fully read Dr Lim’s report; she just read the plan which recommended trialling another anti-depressant. Dr Chiew was not aware of the body of Dr

Lim’s report which referred to Mr Christie’s heightened suicidal thoughts.

The reason Dr Chiew gave for maintaining Mr Christie on Pristiq on 14 December 2012 was that by the time he came to sce her again, he had recommenced Pristiq and he had been taking it for five days. Further, she states he did not mention any side effects of suicidal

thoughts in that visit. The only side effect in her note of that consultation is anxiety.’

'© Transcript p 10.

" Coronial brief p 144.

® Coronial brief p 169.

8 Coronial brief p 144.

41. When asked if her management of Mr Christie would have changed if she had been aware of

the suicide tendencies mentioned in Dr Lim’s letter she stated;

‘I don’t believe so because he stopped the medication after two weeks, then he restarted it and came to tell me that he restarted it because-he initially stopped it because of misunderstanding about the side-effects and he restarted it...when I saw him on 14/12 he didn’t report to me on that day that he had side-effects from Pristiq on the day of consultation. He has restarted Pristiq...it is not a good practice to start switching antidepressant when someone has restarted an antidepressant and has no recurrence of side-

effects.’ 4

42. In his submissions, Mr Halley counsel for Dr Chiew, pointed to material in the coronial brief indicating that Dr Zalman had prescribed Pristiq for Mr Christie on 10 December 2012. Mr Christie and Mrs Garner.also saw Dr Alexopoulas from Vermont Health Care on 15 December 2012 to discuss the side effects of Pristiq. Dr Alexopoulas’ notes state: ‘Not threatening self-harm or suicidality... I think an appointment can be made at a more

appropriate time as there is no immediate risk of self-harm’

43, Mr Halley submitted Dr Chiew’s decision to maintain Mr Christie on Pristiq was reasonable in the context of Dr Zulman having prescribed Pristiq and another GP, Dr Alexopoulas, the next day continuing Mr Christie on Pristig.

44, There appears to be a reasonable clinical basis for Dr Chiew maintaining Mr Christie on Pristig in the context of him having resumed the medication prior to seeing her on 14 December 2012 and her evidence that he did not report a recurrence of side effects. Dr Chiew did concede however, that if she had been fully aware of the contents of Dr Lim’s report, particularly the reference to Mr Christie’s suicidal thoughts, she would have conducted a

suicide risk assessment.

45, There are discrepancies in the evidence on this point regarding Mrs Garner’s recollection and Dr Chiew’s evidence of the consultation and her notes of the same. In her letter of concern dated 11 February 2013, Mrs Garner states Dr Chiew dismissed Mr Christie’s mention of suicidal thoughts.

4 Transcript pp17-18.

'S Coronial brief, p 177.

46, Mrs Garner disputed Dr Chiew’s position that Mr Christie did not report side effects to her on 14 December 2012 and in her statement states: ‘Dr Chiew discarded the suicidal thoughts that Jarrod was having.’!® Mrs Garner’s position is that she attended the appointment with him and he did talk about these thoughts and indeed, the following day he tried to run into traffic.

47, Dr Chiew could not comment on whether Mrs Garner was present at the consultation but stated if it was not in her notes then it was not mentioned by Mr Christic as a side effect. I

give greater weight to her sworn evidence and contemporancous file notes of the consultation

on this point.

48. The fact that Dr Alexopoulas’ consultation notes from 15 December 2012 state Mr Christie was ‘not threatening self-harm or suicidality’ yet Mr Christie was reported by Mrs Garner to attempt to run into traffic the same day reflects the volatile state of Mr Christie’s mental

health at that time.

Management of Mr Christic by Eastern Health

49, On Saturday 15 December 2012, Mr Christie was reported by his mother to intentionally run towards traffic near their house. Mrs Garner describes calling a GP at Vermont Health care (the appointment with Dr Alexopoulas referred to above) and then, in desperation she called Headspace. Headspace triage spoke to Mr Christie on the phone and the CAT team attended

and according to Mrs Garner, ‘convinced us that Jarrod needed to go to hospital.’ "7

50: Mr Christie was subsequently admitted to Maroondah Hospital as a voluntary patient. This

was his first presentation to a mental health service.

51. Maroondah Hospital Inpaticnt Unit 2 has a low dependency unit with 20 beds and a high dependency section with five beds.

52. Mr Christie was initially seen by on call psychiatrist, Dr Baswa, on 16 December 2012, who

decided to discontinue Pristiq and prescribed Lorazepam.'® Dr Baswa’s treatment plan also

included liaising with Mr Christie’s family, private psychiatrist and GP. '°

'6 Coronial brief, pp 7-8.

'? Coronial brief, p 8.

18 Lorazepam is an anti-anxiety drug.

® Coronial brief p 229.

54,

Dr Shameera Rehman was Mr Christie’s consultant psychiatrist at Maroondah Hospital. She first met Mr Christie on 17 December 2012. At the first interview, Dr Rehman described Mr Christie as a ‘diagnostic dilemma since he did not fulfil criteria for a major depressive episode or manic episode or psychosis.’*° She described difficulties making a diagnosis. Mr Christie’s impulsivity may have been part of a manic episode or a personality disorder. It

was unclear if the Pristiq had worsened his mental health, or ‘whether it was a natural sort of

progression into a manic episode.’ *! She also opined his behaviour could have been

‘prodromal for a psychosis.’ She stressed it was very early in diagnostic process and:

‘We tend to go with a watch and wait kind of policy rather than putting him on a whole lot of

medications, so that’s why the medication was given very, very gradually,” With respect to Dr Baswa’s decision to discontinue Pristiq, Dr Rehman stated:

‘.. from all accounts, Pristig seems to have made him more agitated and irritable. So considering the fact that antidepressant can cause what we call is a switch into a manic episode. Sa our tentative diagnosis or our working diagnosis was a bipolar ilness, underlying bipolar illness. And in a bipolar illness antidepressants are not the first line unless the patient is really in a significant depressive episode. So it’s contraindicated in a manic state, So both because of the fact that the antidepressant seems to have made him more irritable and angry and agitated and because the understanding was that it could be an underlying manic episode, plus the fact that he was reporting a worsening of symptoms to Dr

Baswa as well, so that’s the rationale under which Pristiq was ceased.’™

On 19 December 2012, Dr Rehman started Mr Christic on Quetiapine which, she described, *... is an atypical antipsychotic but which also has good effect as a mood stabiliser. And it has also been found to be effective in people who are agitated and anxious, so some of the symptoms that Jarrod was mentioning, I thought that that was the safest to start at that point

until some clarity was obtained.’ *4

28 Statement Dr Rehman, Coronial Brief p 47.

21 Transcript p 4-55.

2 Transcript p 55.

33 Transcript pp 56-57.

4 Transcript p 57.

56. Dr Rehman went on to say she made a working diagnosis of bipolar/mixed episode and Quetiapine would target his ‘anxiety, his agitation, and if there is a mixed episode

underlying, it would target that too."

57. Dr Rehman was asked whether Mr Christic’s symptoms were consistent with discontinuance from Pristiq. She stated: ‘the symptoms that he mentioned [were] there prior to the antidepressants, during the antidepressants and post antidepressants. So it’s a little difficult to tease out whether its actually discontinuance and...he was on a low dose. It was discontinued when he came in, he had discontinued it in the past so it’s difficult to know

whether it was discontinuation symptoms or —it persisted.’ *®

58. In cross-examination on this point, Dr Rehman stated there was a temporal relationship between the worsening of Mr Christie’s symptoms and the commencement of the Pristiq and agreed that the worsening of his symptoms could be related to the natural process of a

psychiatric condition itself. *7

59. Mr Christie’s treatment at Maroondah Hospital was in the context of the principles of the least restrictive practice, using the recovery model in collaboration with the patients needs, goals and aspirations. Dr Rehman described Mr Christie as wanting help and seeking help

from nursing staff.

60. In terms of managing his risk, Dr Rehman stated that the level of observations was one tool used, as well as a dynamic response to the fluid and on-going nature of risk assessment.

Sometimes his risk was assessed as low and at other times high, it was a process of ongoing

review.

61. Dr Rehman also noted it was Mr Christie’s first admission in the public health system which ‘can be quite traumatic for a young person who’s not exposed to...a mental health facility in

a public system...it’s not a nice experience,’ ™®

62, Risk assessments in the low dependency unit occur depending on patient’s risk, at least once

a day but it could vary.

% Transcript p 59.

6 Transcript p 67.

7 Transcript p 91.

8 Transcript pp 69-70.

63,

Dr Rehman met with Mr Christie’s mother and fiancé, Ms Cho on Wednesday 19 December 2012 which was sooner than usual and a meeting at 2.5 hours was longer than usual too. Dr Rehman stressed the importance ‘...in his case to-get that understanding from the family and to get an understanding of the history and chronology of the presentation and the developmental history which has become very important in Jarrod’s case. because, as I said,

his issues...seem to have started right from childhood.’ ”°

Dr Rehman’s statement included a plan to gather further information from the family GP,

psychiatrist and psychologist to assist with diagnostic clarification. *°

At this point Maroondah Hospital did not have Dr Chiew or Dr Lim’s notes of their earlier

consultations with Mr Christie.

On:21 December 2012, Mr Christie absconded from the hospital and tried to jump in front of a bus, He also disclosed sexual activity on the ward. The response was threefold. Firstly at 9pm that evening he was made an involuntary patient. Secondly he was then transferred to the high dependency unit mid-morning on 22 December 2012, Thirdly, there was an increase

to his level of visual observations to every 15 minutes.

Although Dr Rehman’s last contact with Mr Christie was on 19 December 2012, she has reviewed his notes from then until 22 December and stated they suggested to her that his care and treatment was appropriate. She explained that seclusion is not an option for patients who are suicidal, but rather patients who are psychotic, or extremely violent or aggressive; ‘We

obviously cannot restrain a patient because they are suicidal.’ *"

Dr Rehman stated she was being updated daily about Mr Christie at the morning handovers when nursing staff provide updates about issues from the previous day. Further, on the morning of 2] December 2012, prior to his absconding later the same day, Mr Christic’s diagnosis and treatment plan was discussed at length at a weekly clinical review.?* Dr Rehman stated: ‘...even though were not interacting with the patients or the family on a daily basis, we are sort of having the finger on the pulse even behind the scenes.’ * At this

meeting Dr Rehman stated she was still not able to get a good sense of what was happening

2° Transcript p 74.

30 Coronial brief p 48.

3. Transcript p 84.

32 This is a multi-disciplinary team and included the Acting Director of Acute Services, Dr Andrew Chong.

3 Transcript p 86.

with Mr Christie. In her evidence she was unsure whether he was developing a personality

disorder and would have a crisis and evolve, or whether it was early bipolar.

69. On 19 December 2012, Mrs Garner took Mr Christie out on leave to Pines shopping centre.

On the return trip he attempted to jump from the moving car. Mrs Garner was upsct that he was allowed to go on day leave again subsequent to this and she was forced to make up an excuse to avoid it. Dr Rehman stated she could not recall being asked about him going on leave again. ‘It would be very unusual and unlikely... they (nursing staff) would have come and discussed it with me’ >* Dr Rehman was unaware of any hospital policy regarding leave for patients; “...in clinical decision making the nursing staff would come and discuss with the

medical staff. 235

70. When Dr Rehman was asked if she would have changed her treatment of Mr Christie in hindsight, she stated: ‘7 don’t think so...we were struggling with a diagnosis but we had started, empirically the medications. And at every step as the risks were changing, as the clinical presentation was changing, the management was changing as well. So I don’t think

we could have done much differenily.’*°

71, Mr Christic’s change in medication from anti-depressant Pritiq to anti- psychotic Quetapine appears clinically reasonable given the working diagnosis described by Dr Rehman. The change of his status from voluntary to involuntary and then his move to the high dependency unit on 22 December 2012 also appears reasonable in light of his absconding on 21

December 2012 and reported sexual disinhibition.

Mr Christie’s whereabouts at approximately 5pm on 22 December 2012 - How was he able to abscond?

72, On 22 December 2012 two risk assessments were conducted on Mr Christie in the HDU at 12pm and 4.15pm. At both he was noted to be at high risk of suicide and sclf-harm and high

risk of absconding. He was placed on 15 minute observations from 11.30am.

73. Pooji Saini was the associate nurse unit manager in charge of the afternoon shift on 22 December 2012. She allocated two nurses, David Reed and Kevin Williams to the five

patients in the high dependency unit (HDU). As Mr Christie had been made an involuntary

34 Transcript p 88.

% Transcript p 89.

36 Transcript p 171.

74,

patient, Ms Saini was conscious of him needing a statutory review by a psychiatrist within a

24 hour period, which expired at 9pm.

On the afternoon of 22 December 2012, Ms Saini was having a discussion about a patient who was highly agitated in HDU with Dr Keogh and Nurses Reed and Williams, She stated at 5pm she saw Mr Christie in his bedroom (number 22) on her way out of HDU back to nurse base in the low dependency unit. She stated they made eye contact and exchanged

formal smiles.

The evidence is unclear as to whether the discussion about the agitated patient occurred in the nurse’s base, or in the patient’s room, room number 21.7’ David Reed states he and nurse Williams were dealing with the agitated patient, possibly in his room. Both nurse Williams and Reed stated they saw Mr Christie come out of his room at approximately 4.50pm and go into the courtyard. Nurse Williams saw him leave the courtyard, briefly enter the lounge and sit on a couch and then return to his room.*® Nurse Reed states he saw Mr Christie in his

bedroom sitting on his bed, leaning against the wall at 5.00pm.

Ms Saini, nurse Reed and Williams all state they saw Mr Christie in his room at 5.00pm sitting on his bed. When dinner arrived at approximately 5.10pm and Mr Williams went to call patients to dinner, he went into Mr Christic’s room and found it empty. He immediately checked the courtyard, then informed nurses Reed and Hind to search the HDU. Mr Williams had been entering the 15 minute observations of Mr Christie on the observation chart. The last entry sighting Mr Christie is an entry at Spm (‘1700’) noting him to be ‘RIB,’ resting in bed.*? Mr Williams and Ms Saini stated the recording of these observations are made contemporaneously with the observation. Mr Williams stated he was ‘very confident’ and

«100% sure’ that the times of his recorded observations of Mr Christie were accurate.”°

At 5.20pm Ms Saini was advised by Nurse Kate Hind, who was relieving a HDU staff member on their dinner break that Mr Christie was missing. ‘J asked when he was last

sighted, and Kevin informed me that he last sighted Mr Christie at approximately I 700hrs.*!

37 'This discrepancy was referred to by Ms Bianca Christie in her submission to the court, 38 Statement Kevin Reed dated 24/12/2014, p 1.

»? Coronial brief p 190.

4 Transcript p 179.

4 Coronial Brief p 56.

78. In examination by Ms Riddell, Ms Saini explained she had been at the nursing station in HDU discussing an agitated patient who needed injectable medication with Dr Keogh and nurses Reed and Williams, and on leaving HDU she saw Mr Christie; 7 still have a very

clear vision of that.”

79, Ms Saini described being surprised when informed by nurse Hine that Mr Christie was missing; ‘just felt that I’ve just seen him, like before, that was the feeling.’“*When told, Ms

Saini stated she immediately checked her watch and noted it was 17.20 hours.

80, Although he was unobserved, Ms Saini described in her statement that she believed Mr Christie absconded by either climbing over the courtyard wall using a power point as a foothold or alternatively, by being given a boost up and over the wall by a co-patient. She also described the process that took place.following Mr Christie absconding whereby she

notified police and arranged for Mr Christie’s family to be contacted.

81. Mrs Helen Bedggood made a statement and gave evidence to the court. Her evidence was that at about 4.40 pm on 22 December 2012 she was driving on Angus Avenue (near the corner of Ruthven Way), Ringwood East when she saw a man in the drive way of number 41 Angus Avenue. She described him as wearing a black hoodie, some sort of dark pants, like track suit pants that showed his ankles, barefoot, walking around in circles looking confused, After observing him for five minutes, Mrs Bedggood drove to Croydon Police station to

report what she had seen. She estimated the man she had seen to be aged about 30.

82. Mrs Bedggood was cross examined as to the timing of her observations. When asked how she knew the time was 4.40pm, she stated; ‘Well I think it was on my statement when I reached the police station.’ She did not look at her watch and agreed she had ‘a feeling it was

about 4.40pm.’

83. Constable Michael Grey was the officer at Croydon Police station when Mrs Bedggood made her report. His statement indicates he took the report from Mrs Bedggood at approximately 4.55pm. A police communication record was part of the coronial brief which indicates it was created at 17:00:35 from the information Constable Grey received from Mrs Bedggood and

then passed on to Police communications. Constable Grey was concerned that as the person

Transcript p 130.

8 Transcript p 131.

“4 Transcript p 24.

described was wearing no shoes, this suggested he may have escaped from the ‘nearhy psych

ward.

Although the male Mrs Bedggood described sounds similar to Mr Christie, the sequence of timing is at odds with the sworn evidence and statements of Ms Saini, and nurses Reed and Williams. Their evidence was that they saw Mr Christie on his bed in his room at 5.00pm and shortly prior to that he was seen go briefly to the courtyard and then return to his room. The location where Mrs Bedggood made the sighting is in the opposite direction to Heatherdale train station where Mr Christic died. The written record of 15 minute observations of Mr Christie entered contemporaneously by Mr Williams also notes Mr Christie in his bedroom at

5.00pm.

The weight of evidence is with the direct and recorded observations of Mr Christie by hospital staff at 5.00pm on 22 December 2012. The sighting made by Mrs Bedggood appears

to have been coincidental but does not appear to have been Mr Christie.

Action following Mr Christie’s death

Deborah Siddall, nurse unit manager gave evidence that after Mr Christic’s death Maroondah Hospital conducted a root cause analysis, which was completed in February 2013. The power point which may have been a foothold used by Mr Christie to climb the courtyard wall was removed in the week following Mr Christie’s death. As a result of the review, the HDU courtyard walls were extended from 3 metres to 4.3 metres. The walls also now have an aluminium top section, which is shiny and angled inward to limit the potential to climb up

and over. “ This work was completed in July 2013.

Ms Siddall tendered a guideline relating to leave for inpatients from psychiatric inpatients units.? This guideline is to assist the treating team when making decisions about providing leave of absence for voluntary and involuntary patients from the psychiatric inpatient units. “ Dr Rehman was unsure about this guideline: it clarifies a risk assessment should occur after

leave and the carer should be consulted about any issue that arose during leave.

4% Transcript p 35.

46 4 photos of the courtyard as it currently is were marked exhibit 14.

47 Exhibit 13.

48 The document was marked exhibit 13 and was created in 2011.

88, Ms Siddall expressed difficulties the hospital has in obtaining records from GPs or other health professionals regarding medical records for psychiatric in-patients. There does not secm to be a process for obtaining this material. Mr Christie had been at Maroondah Hospital for 7 days. Despite the ‘diagnostic dilemma’ he posed, there was no direct evidence of attempts made by the hospital to obtain his health records which may have assisted his

treating practitioners with formulating a diagnosis.

89. A further change as a result of the root cause analysis was changes to HDU policy to becoming more recovery focussed. Ms Siddall described changes such as the inclusion of recovery goals, and that safe training requirements and aggression management training is

now mandatory for staff.

90. The position of ‘activity nurse’ has been added to HDU in the review of the updated policy.

The activity nurse is to devise activities for patients in HDU and support and assist staff.

Conclusion

93,

94,

95,

99,

There was no Pristiq in Mr Christie’s toxicology report: it did not play a role at the time of his death.

The evidence is cquivocal as to what was the cause of Mr Christic’s deteriorating mental health. His mental health was deteriorating prior. to him commencing Pristiq and then

continued to deteriorate after he ceased Pristiq at Maroondah Hospital.

Mr Christie’s consultant psychiatrist Dr Rehman was unsure what the role of Pristiq was as

compared to the role of his naturally evolving psychiatric condition.

Dr Chiew’s advice to continue with Pristiq on 14 December 2012 was clinically reasonable in the context of Mr Christie’s resumption 5 days prior and not reporting to Dr Chiew

suicidal side effects.

With regards to Mr Christie’s family’s concern that Dr Chiew did not read Dr Lim’s report, Dr Chiew conceded this and indicated she would have conducted a suicide risk assessment

had she done so.

There is evidence of a thorough assessment and treatment rationale by Dr Rehman whereby different diagnosis for Mr Christie were considered. Unfortunately further information from other treatment providers which may have assisted to clarify a diagnosis were not

obtained by Maroondah Hospital prior to Mr Christie absconding.

In light of Mr Christie’s risk assessments, his absconding and sexual disinhibition, his

involuntary status in HDU on 15 minute observations all appear appropriate.

T accept the evidence from nursing staff at Maroondah Hospital as to seeing Mr Christie at 5pm on his bed in his room in HDU. I have given my reasons for accepting the evidence of

nursing staff over Mrs Bedggood’s observations.

The fact that Mr Christie could abscond in the manner suggested represents a failure of the design of the secure space in HDU which has since been remedied by Maroondah Hospital.

I note the change was made immediately to the courtyard in the HDU by removing the

power point and then subsequently by extending the height of the walls in the courtyard.

Whilst in the HDU Mr Christie was assessed as to his clinical risk twice. Unfortunately, delays caused by demanding work load prevented Dr Keogh ftom conducting the statutory

review prior to him absconding. Although still within the 24 hour review period, it is

regrettable that he was not able to be given higher priority given his vulnerability as a

young man on his first presentation to a mental health service in the HDU.

Finding

I find. that Jarrod Christie died from injuries sustained when struck by a train in circumstances

where he intended to end his own life.

I direct a copy of this finding be distributed to:

Mrs Tarnya and Mr Kim Gamer

Chief Psychiatrist Dr Mark Oakley Browne

Constable Lauren Morse

Ms Sue Allen, Chief Counsel, Eastern Health

Mr Jose Segal, Mental Health Program, Eastern Health Mr Michael Averkiou, Department of Transport

Dr Ing Sing Chiew

Interested Parties

Signature:

Za tteprr~ .

CAITLIN ENGLISH CORONER Date: 30 October 2015

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