Christopher Traill's suicide was 'preventable', Coroner's Court of Victoria say

Coroner Audrey Jamieson announced her findings at the conclusion of an inquest into the death of Romsey solicitor Christopher Traill, who was found deceased at Bendigo Health's Adult Acute Unit on February 25, 2017.

Mr Traill had been admitted as a compulsory patient in the facility's Low Dependency Unit one day prior. He had been facing financial difficulties and alcohol dependence issues dating back to his twenties.

He was in his fifties at the time of his death and had five children, and lived with his long-term partner.

In the 12 months leading up to his death it was reported that Mr Traill had stopped enjoying his work as a lawyer and subsequently failed to complete regular business activity statements resulting in a taxation debt of approximately $150,000.

As a result, he was faced bankruptcy - a daunting position he had been in 15 years ago.

OTHER NEWS: Rural melanoma rate concerns lead to call for improved sun protection practices

On February 11, 2017, Mr Traill had been drinking alcohol when he drove to pick up his partner who had been involved in a car accident. He was randomly pulled over by police and breathalysed.

The police officers knew Mr Traill professionally, and he recorded a blood alcohol content (BAC) of 0.155 per cent, resulting in an immediate suspension of his driver's licence.

Mr Traill was aware he would be required to attend the local court where he also practised and he was concerned about the impact this would have on his career and reputation.

Following several medical consultations, where it was deemed Mr Traill had alcohol dependence and major depressive episode, he was admitted Bendigo Health as a compulsory psychiatric patient, under an Assessment Order, On February 24, 2017.

The following day, at 11.06 pm, Mr Traill was located in his room by a nurse, in a non-responsive state.

A Code Blue was called (CPR) was initiated however, he could not be revived and was declared deceased at 11.38 pm. Mr Traill left behind a note.

Coroner Jamieson found based on the evidence and expert evidence, the man's cause of death was suicide.

She also noted it took eight minutes from the time the Code Blue was called for the Code Blue Team to arrive at the Mental Health Unit, partially explained by the fact staff had not long ago moved into the new hospital campus and were still unfamiliar with its layout.

READ MORE: Nays have it on pony club grounds petition to council

Associate Professor and Clinical Director of Mental Health Services at Bendigo Health, Phil Tune told the inquest familiarity with the hospital layout was soon achieved, "and thus ameliorated the risk that such a delay would occur again."

The Coroner said the process utilised by Bendigo Health in removing personal items from compulsory patients upon admission to its mental health facility "lacks clarity", is unsatisfactory and falls below best practice and reflects a systemic problem.

She said objections and outrage from Associate Professor Tune to the suggestion track suit pants could be routinely supplied to patients "was curious, bordered on theatrical" and was generally unhelpful.

"But even more worrying was Associate Professor Tune's reference to a culture within his own hospital that mimicked a classical Monty Python scene rather than the tolerant and inclusive environment he would have me believe he has been involved in creating," the Coroner said.

"His personal views that no one should be allowed to wear tracksuit pants outside their own home was somewhat autocratic and supercilious and clearly made by someone who has not kept up with current acceptable dress codes," she said.

MORE NEWS:

Citing other cases where patients at mental health institutions had died by suicide, Coroner Jamieson said the use of the word tragedy to describe such loss of life in potentially preventable circumstances was appropriate.

She made four recommendations connected to Mr Traill's death, including that Bendigo Health mandate the removal of all personal items that could be used for self-harm, as described as "dangerous items" in the Chief Psychiatrist's guidelines.

She recommended Bendigo Health review its processes related to identifying personal items that have the potential for self harm, and that it should include reference to whose responsibility it is to make the assessment and for that assessment to be documented.

And with the aim of preventing like deaths and promoting public health and safety within a mental health inpatient unit, she recommended Bendigo health implement a practice of providing patients alternative items to replace any personal items removed for risk minimising purposes

Coroner Jamieson found that the lack of clarity surrounding the process for removing personal items that have the potential to be used for harm contributed to the circumstances that facilitated Mr Traill's intentions to harm himself, and that as such, his death was preventable.

A Bendigo Health spokesperson said the organisation offers its sincere and deepest sympathies to Mr Traill's family.

"We have today received Coroner Jamieson's findings and recommendations, which we will review and respond to as part of our culture of continuous improvement," they said.

If you or someone you know needs support, contact: