A coroner has found that failures on the part of Bendigo Health directly contributed to the death of a woman in the health organisation's inpatient mental health unit.
Coroner Simon McGregor held a summary inquest earlier this month after a 46-year-old woman died by suicide in August 2016 while being treated at the Alexander Bayne Centre, which housed Bendigo Health's inpatient mental health services at the time.
On the day of the suicide, the woman - who had been transferred from the high dependency unit to the low dependency unit the previous day - was supposed to be checked at 60-minute intervals.
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She was seen at 11am, but was not checked at noon because the nurses assigned to the low dependency unit went to the high dependency unit at 11.50am to assist fellow staff with restraining an abusive patient.
The woman's care was not handed over to another nurse.
She was found injured about 12.20pm and died two days later.
In the days and weeks before her death, the woman had expressed suicidal thoughts and had been found in the Alexander Bayne Centre with an item similar to that she ultimately used to end her life.
Mr McGregor found that Bendigo Health had failed to ensure there were sufficient staff to carry out the hourly observation on the woman at noon, and this failure directly contributed to her death.
He said "if staff had discovered her twenty minutes earlier it is certain that her chances of survival would have been distinctly higher".
"Failing to ensure that this observation occurred was a material departure from the standards to be expected of an acute inpatient psychiatric unit, and there is sufficient evidence for me to conclude that it directly contributed to [the woman's] death," Mr McGregor said.
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Mr McGregor concluded that Bendigo Health's failure to ensure the woman did not have access to an item she used to carry out her suicide, also played a direct role in her death.
He said the inpatient unit should have been free of available means of suicide.
The woman did not receive additional medication on the morning of the suicide and while it would have been reasonable for her to do so given her agitation and distress, Mr McGregor found, there was insufficient evidence that this had contributed to her death.
The coroner also found that staff should have carried out a formal risk assessment on the woman in accordance with Bendigo Health policies, but failed to do so.
He said multiple staff had underestimated the woman's suicide risk, although this did not appear to have had a direct impact on the treatment she received.
Mr McGregor recommended Bendigo Health change its regular audit of a particular suicide means to formally include the item the woman was found with.
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He also recommended Bendigo Health amend protocols to ensure that, when a patient is found with a prohibited item, reasonable efforts are made to find out how they gained possession of the item and steps are taken to prevent future access to such items.
But he noted the organisation had already made changes in the wake of the woman's death.
"I commend the work they have undertaken to protect their patients and prevent deaths such as [the woman's] from occurring in the future, and I am confident that this work will continue," Mr McGregor said.
These include changes to staff training, including responses to patient escalation, processes to prevent non-compliance with risk assessment guidelines, and
The findings also reported that the hospital had developed a system to formalise how staff are moved between the low dependency and high dependency units, educated staff, and identified specific responders, for events when extra resources were needed.
A Bendigo Health spokesperson said, "Bendigo Health accepts the findings of Coroner McGregor and will implement the recommendations in full".
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