Record of Investigation Into Death
I, Christopher P Webster, Coroner, having investigated the death of
Alastair James Douglas McLeod
WITH AN INQUEST HELD AT HOBART
in Tasmania on 4 and 5 November 2010
(a) Alastair James Douglas McLeod ("Mr McLeod") died on 24 April 2009 at the Hobart Clinic at Chipmans Road, Rokeby in Tasmania.
(b) Mr McLeod was born in London, United Kingdom on 8 March 1967. He was unemployed at the time of his death.
(c) Mr McLeod died as the result of asphyxia due to deliberately hanging himself in his room at the Hobart Clinic, at Rokeby.
(d) No other person contributed to the cause of Mr McLeod's death.
A formal Inquest was held into the circumstances surrounding the death of Alastair James Douglas McLeod on 4 and 5 November 2009.
Sergeant Gerard Kirkham, attached to the Coroners Office, acted as Counsel assisting the Coroner.
Various interested parties were represented at the Inquest, namely:
(a) Nurses Cheryle Williams and Sheryl Tatham, represented by Mr R Phillips and Mr G Dolliver (of Phillips Taglieri);
(b) The Hobart Clinic, represented by Mr D Barclay and Mr B Cassidy (of Page Seager);
(c) Nurse Walter Meier, represented by Mr Tom Cox (Barrister) and Mr M Barnier (of Hunt & Hunt);
(d) Dr S Hooper, represented by Mr C Cunningham (of Simmons Wolfhagen).
The totality of the Coroner's file was tendered into evidence. This file included, amongst other items, Mr McLeod's medical records from the Royal Hobart Hospital; pathologists report; clinical notes from the Hobart Clinic; photographs, video of movements at the Hobart Clinic on 24 April 2009, and affidavits of all witnesses.
The following witnesses appeared at the Inquest and were cross-examined on their affidavits, namely:
(a) Matthew Cane and Andrew Summers - Intensive Care Paramedics who were the attending ambulance officers on 24 April 2009 at the Hobart Clinic.
(b)Amanda Quealy - Chief Executive Officer of the Hobart Clinic.
(c) Constable George Stirling - the Police Officer who first attended the Hobart Clinic on 24 April 2009, following the death of Mr McLeod.
(d) Dr Stewart Hooper - the Clinical Director of the Hobart Clinic.
(e)Peter Fraser - the Clinical Services Manager at the Hobart Clinic.
(f) Cheryle Williams - Nurse at the Hobart Clinic.
(g) Sheryl Tatham - Nurse at the Hobart Clinic.
(h) Walter Meier - Nurse at the Hobart Clinic.
In addition to the Coroner's file the following documents were tendered by various parties during the Inquest, namely:
(a) Policy & Procedure Manuals of the Hobart Clinic;
(b) Report of the organisational-wide survey for the ACHS Evaluation and Quality Improvement Program - Hobart Clinic;
(c) Agreement between the Hobart Clinic and Patients relating to use of drugs and alcohol in the Clinic;
(d) Final Report - Root Cause Analysis Incident Report;
(e) DVD security analysis;
(f) Opinion of Dr Konrad? Blackman - Review of Events Pertaining to Alastair McLeod.
Circumstances Surrounding the Death -
The Hobart Clinic is a privately funded psychiatric hospital for private patients. It is a hospital for patients who have a motivation to get well, and funding to attend. It is not for the critically unwell or for persons with actual suicidal intentions. These patients are not accepted and a triage system exists to ensure that such patients are sent to other mental institutions who have the facilities to ensure safe care for such patients.
As the patients are private the Hobart Clinic has no power, apart from a contract between the patient and the hospital, to keep patients in the Hobart Clinic. The ultimate power of the Hobart Clinic over patients is to exclude the patient from attending the Hobart Clinic, or if medical grounds exist, to transfer that patient to another hospital or mental institution.
Mr McLeod had a history of admissions over the years to the Hobart Clinic, and had had some 7 admissions to the Clinic for poly substance abuse and on one occasion for depression.
On 14 April 2009 he was admitted to the Hobart Clinic for injuries sustained in a motor accident.
At the time of admission he was not regarded as a serious risk of suicide. He was assigned Category 2 status, which was reduced to Category 3 (the lowest indicator of suicide), on 17 April 2009.
On the evening of 23 April 2009 at approximately 11.45pm Mr McLeod was found by staff at the Clinic to be absent without leave. At 7.30am the next day, 24 April, Mr McLeod returned, of his own volition, to the Hobart Clinic.
Mr McLeod upon his return spoke to nurses and Nurse Meier at the nurses station. At that time a mini mental assessment was undertaken by Nurse Williams. Neither Nurse Williams nor Nurse Meier detected anything unusual in Mr McLeod's manner which caused any alarm. Mr McLeod went to his room. That room being the furthest room away from the Reception area (i.e. approximately 300 metres distant).
Nurse Meier attended Mr McLeod's room 12 minutes later. The door was barred and Nurse Meier had to force his way into the room using considerable force. Upon entering the room at 7.54am Nurse Meier found Mr McLeod hanging on the shower frame by a belt.
Nurse Meier made an attempt to get Mr McLeod down but was unable to do so. He checked for signs of life but there are no signs. He then left the room to seek Nurse Williams assistance. Both nurses then returned to Mr McLeod's room where Nurse Williams also checked unsuccessfully for signs of life. They still could not release Mr McLeod.
Nurse Williams then returned to the nurses station to make emergency calls and other necessary telephone calls. While Nurse Williams was making these calls, Nurse Meier was able to lift Mr McLeod and cut the belt.
At about the time that Nurse Meier released Mr McLeod, Nurse Tatham, who had been directed by Nurse Williams to assist Nurse Meier, arrived at Mr McLeod's room.
Nurse Meier described what happened initially when he located the body as follows:
"I tried to lift him - standing there and tried to lift him to undo the belt, but I couldn't, I mean he was over 100 kilos, so I thought, oh you know, try again and then I tried again but it was hopeless, and then I went to see Cheryle Williams"
He described what happened when he was left by Nurse Williams when she went to make the telephone calls as follows:
"And then by that time Cheryle - Cheryle Williams had left and Sheryl Tatham came (approximately 8.01am) and she also took the carotid pulse and shook her head … we all felt that he was dead and we couldn't do anything anymore the way he was and we couldn't move him and we could not move him from exactly the position where he was, we could not even attempt CPR - and not apply - or apply the defibrillator. So we just - as I said I was exhausted and Sheryl Tatham came as I said and took the pulse and then Cheryle Williams came back (approximately 8.06am) and said the ambulance is coming so we actually left - left the trolley in that position … [and then made the room tidy for the ambulance … and then we went to check on the other patients and by that time the ambulance had arrived]"
The ambulance crew entered Mr McLeod's room 20 minutes, after Mr Meier had first entered his room, and unsuccessfully began resuscitation measures.
Mr McLeod's treatment was continued by ambulance officers and while being transported by the ambulance to the Royal Hobart Hospital Mr McLeod was declared dead.
Causes of Death
The cause of Mr McLeod's death was asphyxia, as a result of hanging himself by his belt from the shower frame in his room at the Hobart Clinic.
The primary reason that a formal Inquest has been held into the death of Mr McLeod was to ascertain whether there was any person that contributed to his death, and if so, whether measures could be introduced or improved so as to prevent a similar death.
The actions of the Hobart Clinic and the individual nurses will be considered.
(a)The Hobart Clinic
There was no evidence that the staffing levels generally at the time of Mr McLeod's death were inadequate.
The staffing level generally is 1 psychiatric nurse for every 7 patients. At the time of the death there were 2 nurses for 10 inpatients. This level of staffing exceeded the recommended levels.
The nurses had been nurses for many years. Nurse Williams was a nurse for 30 years and a psychiatric nurse for 11 years. Nurse Meier had been a psychiatric nurse for at least 19 years.
Adequate equipment was provided for the assistance of the nurses. There was a "crash trolley" containing all necessary equipment to enable the nurses to attempt to resuscitate Mr McLeod, and the nurses were trained and capable of using such equipment. There cannot be said to be any failure by the Hobart Clinic in failing to equip the Clinic with adequate staffing and equipment.
The question of not removing "hanging points" at the Hobart Clinic was raised. I do not consider that the Hobart Clinic was remiss in failing to remove "hanging points" to deter or prevent suicides or that the existence of "hanging points" contributed to Mr McLeod's death for the following reasons:
(i) Mr McLeod was a voluntary patient. If he had wished he could have left the Hobart Clinic at any time, which is in fact what he did the preceding night. If a "hanging point" was not available inside the Hobart Clinic he could have hanged himself elsewhere or committed suicide by other means.
(ii) The Hobart Clinic is an institution for persons at "low risk of suicide" and is a voluntary institution. It is unlikely that the conversion of the Hobart Clinic into a completely suicide proof institution is likely to create an atmosphere that would attract fee paying clients or that the cost would be justified by the actual risk of suicide. In any event the Hobart Clinic appears to have passed Quality Assurance checks by the relevant body.
I am satisfied that there was an appropriate risk assessment procedure in place for patients returning to the Hobart Clinic and that in fact such an assessment was undertaken by Nurses Williams and Meir on the morning of 24 April 2009. Nurse Meier went to check on Mr McLeod within 15 minutes of the readmission to the Hobart Clinic in any event, which was in essence the procedure that would have been followed even if Mr McLeod's category of risk had been increased on his re-admittance.
There is the question of whether failure to notify family of the absence of Mr McLeod on the night of 23 April 2009 contributed to his death. I do not consider that it did or that it was necessary for Mr McLeod's family to be notified of his absence.
The absence was relatively short and occurred late at night. It is unlikely that Mr McLeod's family could have done anything about his absence, but even if they had it is probable that he either would have been taken back to the Hobart Clinic or counselled to return to the Clinic. Whether he could have been located prior to consuming the illicit drugs and alcohol, which may or may not have affected his state of mind making him commit suicide, is purely problematical.
His death did not occur outside the Hobart Clinic. The Clinic had no authority to notify the police of his absence from the Clinic.
Since the death of Mr McLeod the Hobart Clinic has comprehensively reviewed their policies and appear to have adequate policies in place. There is no need to make recommendations in respect to the practice and procedure of the Hobart Clinic.
Nurse Sheryl Tatham
Nurse Tatham was qualified as a nurse. She was employed in other areas by the Hobart Clinic.
Nurse Tatham arrived at work at 8.00am and was directed to assist Nurse Meier by Nurse Williams, who was at that stage making appropriate telephone calls.
Nurse Tatham's knowledge of the events when she arrived at Mr McLeod's room were sketchy at best. When she arrived at Mr McLeod's room and felt his pulse, and was satisfied he was dead, it was appropriate for Nurse Tatham not to take her directions from Nurse Meier as she did not know the preceding history and she was not employed as a nurse.
Nurse Tatham's behaviour was appropriate in all the circumstances and in no way contributed to the death of Mr McLeod.
Nurse Cheryle Williams
Nurse Williams conducted a mini assessment of Mr McLeod on his arrival back at the Hobart Clinic. There was nothing apparently unusual with Mr McLeod.
Within 15 minutes of Mr McLeod being re-admitted Nurse Meier was at Mr McLeod's room so that it could not be said that either Nurse Williams nor Nurse Meier were not keeping Mr McLeod under observation upon his return to the Hobart Clinic.
Nurse Williams appears to have done all that she could to assist Nurse Meier with Mr McLeod on the day.
She attended Mr McLeod's room with Nurse Meier as soon as requested. She took Mr McLeod's pulse. She assisted Nurse Meier in trying to lower Mr McLeod from the shower bay, and she brought the trolley to Nurse Meier. She then went to the nurses station to make appropriate telephone calls.
No criticism can be made of Nurse Williams' actions.
Nurse Walter Meier
The two questions concerning the actions of Nurse Meier are whether his (or the other nurses) failure to perform CPR on Mr McLeod contributed to the death of Mr McLeod, and whether he should be criticised for his failure to perform CPR.
The evidence presented at the Inquest was to the effect that even if CPR had been administered by Nurse Meier (or others) in a timely manner (i.e. as soon as he was lowered to the ground), the chances of a successful resuscitation were remote.
The evidence of both ambulance attendants was that the chances of resuscitation in the circumstances of Mr McLeod were small. Paramedic Cane state that the window of opportunity for a successful resuscitation expires after 4 to 15 minutes, and that after that time Mr McLeod's prospects were not improved by CPR, using compression or oxygen.
The report of Doctor Konrad Blackburn, Staff Specialist, Emergency Medicine Royal Hobart Hospital indicated that the prospects of a better outcome for Mr McLeod were extremely remote. His evidence was that after 20 minutes Mr McLeod had no prospects of a successful resuscitation.
Statistics referred to by Doctor Blackburn showed survival from cardiac arrest in any case is low:"A recent review pooling data from 79 studies (14 x 740 patients) showed that 23.8% survived to be admitted to a hospital. Only 7.6% survive to be discharged from that hospital".
In light of this evidence I am unable to conclude that Nurse Meier's failure to administer CPR contributed to the death of Mr McLeod. The lack of a chance of success is however not in itself sufficient reason for anyone, particularly a trained nurse, not to administer CPR in circumstances such as those surrounding Mr McLeod. If such an approach were universally adopted a significant number of persons (though statistically small) would needlessly die. CPR should be administered where possible and practical.
In the case of Nurse Meier I accept that the failure to administer CPR was due to factors beyond his control and he should not be criticised for failing to administer CPR for the following reasons:
Nurse Meir was physically exhausted as a result of the cumulative effects of moving quickly from the Reception desk to Mr McLeod's room on at least three occasions; attempting on at least three occasions to lift Mr McLeod who weighed approximately 100kg (i.e. a heavy weight), and supporting Mr McLeod's weight with one arm while he cut him down.
The room in which Mr McLeod was lying after being lowered to the floor did not allow Nurse Meier to effectively administer CPR, and Mr McLeod's body could not be easily moved. This version is supported by the evidence of the two paramedics, who while both young and fit, had difficulty in moving Mr McLeod's body.
(c) Ambulance Staff
After the adjournment of the hearing of the Inquest I received a letter which raised questions about the lack of training of the members of the first ambulance crew to arrive at the Hobart Clinic on 24 April 2009.
A copy of that letter was sent to all Counsel participating in the Inquest for their comment.
I do not propose to enlarge the Inquiry of the Coroner to include the possible lack of training of the staff in one of the attending ambulances.
Paramedics Cane and Summers gave evidence of their treatment of Mr McLeod. I am satisfied that their treatment was both appropriate and given in a timely manner. Any delay that occurred in the administration of treatment between the time the team involving Cane and Summers commenced giving treatment, and when the first team could have given treatment was very limited.
The paramedics did not arrive until approximately 20 minutes after the discovery of the body and any treatment administered by the first paramedic team after 20 minutes was extremely unlikely to result in resuscitation for the reasons stated by Doctor Konrad Blackburn.
I consider the matters raised in the letter to be too remote from the question of cause of death to investigate further. A line must be drawn at some point beyond which factors which come to light will be considered as too remote from the death.
Before I conclude this matter, I wish to convey my sincere condolences to the family of the deceased.
This matter is now concluded.
DATED: 11 January 2011, at Hobart in the State of Tasmania
Christopher P Webster