In The Matter of The
Coroners Act 1995
In The Matter of an Inquest
Touching the Death Of
Claire Louise Waugh
FINDINGS, RECOMMENDATIONS AND COMMENTS of Coroner Rod Chandler following an inquest held in Launceston on various dates between November 2009 and December 2010.
29 September 2011
Claire Louise Waugh (‘Ms Waugh’) died on 9 January 2008 at Ward 1E in the Launceston General Hospital (‘the LGH’). In more recent times Ward 1E has been re-named Northside but for the purposes of these findings I will refer to it by its previous name. At the time of her death Ms Waugh was being detained as an involuntary patient under a Continuing Care Order made pursuant to s28 of the Mental Health Act 1996. As such, Ms Waugh was a "person held in care" as defined in the Coroners Act 1995 (‘the Act’). As required by the Act (s24(1)(b)) I have conducted an inquest into Ms Waugh’s death. I am now able to set out an account of the circumstances surrounding her death and to make those findings and, as necessary, the recommendations, comments and reports required by s28 of the Act.
Circumstances Preceding Ms Waugh's Death
Ms Waugh was born on 10 August 1985 and was aged 22 years. She was the mother of two children aged 2 and 4 years.
In 2004 Ms Waugh was treated for postnatal depression and cannabis abuse at the Mersey General Hospital in Latrobe. From May to July 2006 she was an inpatient of Ward 1E at the LGH when she was diagnosed with paranoid schizophrenia and cannabis and amphetamine abuse. She was discharged on a combination of two antipsychotic medications, Ariprazole and Olanzapine. Following discharge she was reviewed by the outpatient service of the LGH, her last consultation being on 27 September 2007. Her mental state at that time was stable with no mood or psychotic symptoms. She reported no use of illicit substances.
At Christmas 2007 differences arose between Ms Waugh and her former partner. He took her children interstate and she had difficulty maintaining contact/access to them. Ms Waugh then resumed using cannabis and amphetamines and ceased taking her antipsychotic medication.
In the evening of 5 January 2008 police attended an incident at a restaurant in York Town Square in Launceston involving Ms Waugh and her companion Colin Harrison. It was reported to police that earlier that day Ms Waugh had consumed illicit drugs, that she had since been behaving erratically and that she had threatened to stab Mr Harrison with a knife. The attending police were concerned by Ms Waugh’s mental state. They accompanied her to the LGH where she was received in the Department of Emergency Medicine (‘DEM’). There, she was initially seen by resident medical officer, Dr Sven Richter. In his view Ms Waugh appeared to be suffering a mental illness and he considered it appropriate to make an Initial Order under s26 of the Mental Health Act 1996 enabling her to be detained as an involuntary patient. Dr Richter then referred Ms Waugh for assessment by Dr B L Sketcher, the on-call Registrar in Psychiatry. Dr Sketcher undertook that assessment beginning at 0030 on 6 January. Ms Waugh reported to Dr Sketcher that her relationship with Mr Harrison was unsatisfactory with him being abusive to her, both verbally and physically. However, she said that her chief complaint was that there was a conspiracy against her to prevent her from having contact with her two infant children. She reported many people to be in on the conspiracy including a taxi driver whom she had seen earlier in the day. Ms Waugh also reported to Dr Sketcher that she was using cannabis daily and that she was also taking amphetamines bought illicitly. She denied intravenous drug use or the use of any other illicit substances. Following a mental state examination Dr Sketcher concluded that Ms Waugh was suffering "psychotic symptoms (mainly persecutory ideation) in the context of amphetamine and cannabis misuse, and in the context of a number of social stressors, including living in a domestically violent home and having difficulties gaining access to her children in Melbourne." Dr Sketcher confirmed the Interim Order made by Dr Richter and authorised her admission to the psychiatric ward (Ward 1E). At the time of his assessment Dr Sketcher observed that there was evidence of impulsivity, poor judgement and chronic risk issues, but he did not consider there was any evidence of immediate risk by Ms Waugh to herself or others. She was thus classed as a Category 3 patient for the purposes of nursing observation. This obligated nursing staff in Ward 1E to maintain 30 minute observations of Ms Waugh. This is a subject which I will consider in more detail later in these findings.
Ms Waugh was received on to Ward 1E in the early hours of 6 January. A brief psychiatric rating scale was completed by Registered Nurse Penno. Relevantly it shows that no symptoms were present indicating depression or suicidality. Progress notes made by Nurse Penno indicate that Ms Waugh’s mother had been telephoned and "notified of Claire’s situation." Later that morning Ms Waugh spoke to her mother by telephone. She took the call in the lounge room and it was overheard by Nurse Ron Aston. He has recorded that the conversation started well but then came a "shouting outburst" when Ms Waugh claimed that her mother would not believe her when she said "the outlaws from Victoria are here to kill her." Nurse Aston says at this time that Ms Waugh threw a cup of coffee onto the ceiling but that she later settled and began interacting with other patients.
On the morning of 7 January Ms Waugh was seen by consultant psychiatrist, Dr Otto Gruebel and psychiatric registrar, Dr Nenad Alempijevic. Ms Waugh was known to Dr Alempijevic, he having been involved in her outpatient care following her 2006 hospitalisation. He had seen her at the time of her last consultation on 27 September 2007.
Of the examination on 7 January Dr Alempijevic reports that Ms Waugh "was unwell with prominent paranoid delusions." Nevertheless, in his view she had good insight into her problems and her need for treatment. She considered that her mental state had deteriorated because she had ceased taking the anti-psychotic drug Aripiprazole and had begun abusing cannabis and amphetamines. It was decided to restart treating Ms Waugh with anti-psychotic medication and she was prescribed Olanzapine beginning with a dose of 5 mg twice daily for the first day and then to be increased to 10 mg twice daily.
Nurse Georgia Freeman was assigned to Ms Waugh’s care during the day shift (from 7.00am to 3.30pm) on 7 January. The progress notes made by Ms Freeman show that early in the day Ms Waugh was "unpredictable in mood………Very paranoid and suspicious of those around her……." Nurse Freeman has also noted that during that morning Ms Waugh spoke to Mr Harrison on the telephone and he later visited Ward 1E with some clothes for her. She has recorded in the notes, "Claire asked him not to return." It was Nurse Freeman’s evidence that she made that particular entry in the notes because Ms Waugh’s contact that morning with Mr Harrison had caused her distress and it was her expectation that other staff would read the entry and would be cautious about permitting Ms Waugh to have either in-person or ‘phone contact with Mr Harrison. That same morning Ms Waugh also spoke to her mother by telephone who indicated that she would be visiting her daughter later that day with her partner. Ms Waugh stated to Nurse Freeman that she was "worried about (her) step-dad coming as it will impinge on what she is able to talk about with her mum." It was the further evidence of Nurse Freeman that the two ‘phone calls that morning caused distress to Ms Waugh.
Nurse Kathleen Szolna was also on duty for the day shift on 7 January. She observed an incident in the afternoon of that day lasting 5 to 10 minutes where Ms Waugh was "extremely upset and hallucinating and agitated. She was screaming…….she was describing in detail horrific visions……she believed her children were tied up in her backyard and were being raped…." In Nurse Szolna’s opinion Ms Waugh "was very unwell and it would take her a long time to get well."
Nurse Lorraine Lee-Archer was the nurse responsible for Ms Waugh’s care during the afternoon shift (from 1.30pm. to 10.00pm.) of 7 January. She recorded that during that shift, "Claire’s mood has fluctuated and ranged from angry to alert and co-operative." It was Nurse Lee-Archer’s evidence that Ms Waugh responded "in a positive manner" to this ‘phone contact with her children.
That evening Ms Waugh was visited by her mother Lynette Wright and her partner. They took with them some items that Ms Waugh had asked for including cigarettes, a framed photograph of her daughters and an old mobile ‘phone which did not have any credit but which had on it a video of Ms Waugh with her mother and daughters. When they arrived staff were taking a blood sample from Ms Waugh. Afterwards Ms Waugh and her mother were together in the courtyard. There was another female patient in that area who was staring at Ms Waugh. Ms Waugh suddenly assaulted the other patient and had to be restrained by Ms Wright’s partner. Ms Wright described her daughter at this time as being "very psychotic." Ms Wright and her partner had some time in Ms Waugh’s room before they left. They "just talked." Ms Waugh indicated that "she was really concerned that she had lost her 2 girls for good."
Ms Waugh was next reviewed by Dr Gruebel and Dr Alempijevic during their ward round in the morning of 8 January. Dr Alempijevic has noted that at that time Ms Waugh presented as being "very unwell." It was considered appropriate at that time for a continuing care order to be made and this was subsequently formalised for a period of three months. That morning Nurse Lee-Archer was again the nurse responsible for Ms Waugh’s care. She describes Ms Waugh’s mental state at that time as being "labile………fluctuating between co-operative and angry." She further records in the records that Ms Waugh "continues to believe that people are against her, believing her to be a bad person/bad mother." Nurse Lynette Brooks who was also working on the early shift that day observed in the late morning an incident where Ms Waugh was standing alongside a table tennis table with a bat in her hand. She was "saying things like ‘they’re after me’ and then she slammed the bat into the……table." Nurse Brooks says that she tried to talk to Ms Waugh but she ignored her and walked off.
Nurse Szolna was the nurse-in-charge of the day shift on 8 January. She described Ms Waugh’s state in the morning to be "reasonable" but says that in the afternoon she was "distressed and hallucinating." She considered that she was "a high risk to herself and others." It was Nurse Szolna’s further evidence that in the afternoon of 8 January Nurse Brookes, whom she believed was the nurse assigned to Ms Waugh’s care during that shift, came to her to say that she was concerned for Ms Waugh’s safety because she was "very upset and hallucinating again." She said that they discussed the option of placing Ms Waugh in the High Dependency Unit (‘HDU’) for the safety of both herself and the other patients and it was Nurse Szolna’s recollection that at least at some stage between 6 and 9 January Ms Waugh was placed in this Unit. It needs to be explained that HDU is a unit within Ward 1E but separate from the body of the ward which is purpose designed to provide isolated and secure accommodation usually for those patients, who by reason of their illness present a real and serious risk of causing harm to themselves or to others. The unit is located so that nursing staff are able to maintain constant observation of any occupant.
It was the evidence of Nurse Brooks that she could not recall a discussion with Nurse Szolna concerning Ms Waugh on 8 January but "it could have been possible." She also had a recollection of seeing Ms Waugh in HDU during this period. However, she acknowledged that if the HDU register did not have an entry showing Ms Waugh to have been admitted then it’s likely that she had not been formally admitted at this time. She accepted that if she saw Ms Waugh in the HDU at this time then the likelihood is that it was being utilised by her for "some time out" or "some quiet time" without her being formally admitted.
Nurse Kathryn Austin was the nurse assigned to care for Ms Waugh on the afternoon shift of 8 January. Several days previously she had participated with Dr Sketcher in the dual assessment undertaken when Ms Waugh presented in DEM. She has recorded that on 8 January Ms Waugh told her that she was feeling up and down but this did not cause Nurse Austin any concern. She also observed her fraternising with other patients "and she had no difficulties."
At about 8.00am on 9 January Ms Waugh approached Nurse Malcolm Farmer who was the nurse allocated to care for her that day. She was agitated and requested medication. Nurse Farmer sat and had a chat with her. However, he was unable to glean the cause of her agitation. He gave Ms Waugh her morning medication and this, coupled with their conversation "calmed her down." Nurse Farmer has recorded that later that day Ms Waugh received a ‘phone call from her mother-in-law which enabled her to speak to her children and that she "enjoyed this contact." At the time he finished his shift that afternoon Nurse Farmer said that he was not concerned by Ms Waugh’s behaviour and that he did not consider she was at risk of self-harm.
On 9 January Nurse Lee-Archer resumed work on the afternoon shift. Ms Waugh was again one of the patients assigned to her. During the course of the afternoon she observed Ms Waugh to be angry and agitated with other patients because she believed they were talking about her. Nurse Lee-Archer had several conversations with Ms Waugh and was able to "de-escalate" her without needing to resort to medication. It was Nurse Lee-Archer’s further evidence that at about teatime she observed Ms Waugh walking alongside a male patient whom she was aware made her uncomfortable. Nurse Lee-Archer suggested to Ms Waugh that she "find her own space" and she then moved away from the other patient.
Nurse Brooks was also working on the afternoon shift of 9 January. She says that at about 5.30pm she noticed Ms Waugh sitting in the lounge room watching television and eating her tea. She saw that she had eaten all of her meal which was unusual. About 15 to 20 minutes later Nurse Brooks observed Ms Waugh sitting in the lounge room when the water in a nearby water cooler was changed by Nurse Aston. After this Nurse Brooks went to the dining room to attend an agitated patient. It was her further evidence that at about 7.05pm. she was administering medication to her patient in the dining room when she observed Ms Waugh walk by. She asked her if she was alright to which she replied, "Yes Lyn, I’m fine." Nurse Brooks then observed Ms Waugh enter her room and close the door behind her. A short while after this Nurse Brooks went to the nurse’s station to write up some patient notes.
Nurse Lee-Archer was also in the nurse’s station attending to some paperwork when she realised that she hadn’t seen Ms Waugh "for a while." Nurse Brooks, who was present, then said that she had seen her at about 7.00pm. Nurse Lee-Archer recorded this on the observation sheet by writing the letters "L/R" (denoting lounge room) alongside the time 1900 hours. After this Nurse Lee-Archer left the nurse’s station and went to Ms Waugh’s room. She opened the door and found Ms Waugh lying behind it on the floor. She noticed a bed sheet tied around her neck. She shouted out for someone to call a Code Blue. Ms Waugh was pale and cold to touch. Nurse Lee-Archer removed the sheet. She could not detect a pulse. She immediately commenced CPR. The records show that the Code Blue was called at 7.16pm and that the Code Blue team arrived at 7.20pm. It took over the CPR but was unable to revive Ms Waugh. Life was declared extinct at 7.40pm.
State Forensic Pathologist Dr Christopher Lawrence carried out a post-mortem examination. Toxicology testing revealed methylamphetamine (less than 0.04 mg/L), THC, the major psychoactive constituent of cannabis (0.2 mg/L) and olanzapine (greater than therapeutic level of 0.2 mg/L). Dr Lawrence comments that the mildly elevated level of olanzapine "may represent post-mortem redistribution and is probably not clinically significant." He states the cause of death to be hanging following methylamphetamine use.
Matters Arising From Ms Waugh's Death.
The circumstances surrounding Ms Waugh’s death has given rise to a number of issues. It’s necessary that I deal with each in turn.
Categorisation and Related Matters
At the time of Ms Waugh’s death Ward 1E had in place a written policy (Continuum of Care Number 6) stipulating nursing observation categories for its patients. The Policy’s aim is to ensure that staff maintain appropriate levels of observation to maximise the proper management and safety of patients. The policy prescribes four category types. Category 1 patients are those assessed to be at serious and imminent risk of causing harm either to themselves or others. Patients assessed to be within this category are to be cared for on a one-to-one nurse/patient ratio with the responsible nurse being required to remain with the patient constantly and to be within both visual and touching distance at all times, including escorting the patient to the shower/toilet. Patients are assigned the Special 2 category status when, either by behaviour or verbalisation they are assessed to present a probable risk to themselves, others or property. Although such patients are significantly disturbed they are assessed not to require the constant specialing required for Category 1 patients. Rather, for such patients the policy obligates the allocated nurse to have a knowledge of the patient’s whereabouts on the ward and to visually check him/her at least every 15 minutes including overnight. The policy provides that a patient will qualify under Category 3 if he/she falls into one of four groups. The first is that they are psychiatrically ill but do not present a danger to themselves or others. The second is that they have a psychiatric illness that is improving with medical and psycho-social intervention. The third is the presence of an ambiguity in assuring personal safety. The fourth is where conversation/behaviour identifies medium level risk of harm to self or others. A patient assessed to be within Category 3 obligates the allocated nurse to visually check such patients each hour and for the observations to be recorded on a Nursing Observation Recording form. That form requires completion of the date, the actual time of sighting, the place the patient was sighted and the name of the staff member sighting the patient. Category 4 patients are ordinarily those approaching discharge where the symptoms/problems arising from their mental illness have virtually abated. The Category also includes those patients who understand and accept the need to be in hospital and who are able to give assurance of personal safety. The policy requires the whereabouts of Category 4 patients to be noted by the allocated nurse at intervals not exceeding two hours and for the same details to be recorded on the Nursing Observation Recording form.
When Ms Waugh was first seen by Dr Sketcher in the early hours of 6 January he assessed her to be a Category 3 patient. This categorisation continued to the time of her death. It implied that it was appropriate for Ms Waugh to be accommodated within the non-HDU section of Ward 1E. It meant that each nurse allocated on each shift to care for Ms Waugh was required by the policy to visually check her each hour and to complete the Nursing Observation Recording form. However, it was the evidence of Ms Jeanette Dorman, Ward 1E’s Nursing Unit Manager, that the ward was trialling 30 minute observation periods for Category 3 patients at this time and that Ms Waugh was subject to this half hourly regime and not to the one hourly checks stipulated by the policy. This is confirmed by the Nursing Observation Recording forms forming part of Ms Waugh’s records which show for the period 6 January to 9 January inclusive that Ms Waugh remained a Category 3 patient and was observed each half hour. The question arises whether Ms Waugh’s classification as a Category 3 patient requiring half hourly observations was appropriate, particularly on the day of her death? Alternatively, did the seriousness of her illness require either her placement in the High Dependency Unit (‘HDU’) or her retention within the non-HDU section of Ward 1E but subject to the levels of observation required of a Category 1 or Category 2 patient?
Professor Nicholas Keks is an experienced practising psychiatrist who, at the time of the inquest, was Head of Psychiatry at Epworth Hospital in Melbourne and was adjunct Professor of Psychiatry at Monash University. He prepared a report for the inquest and also gave evidence in person. Relevant to the issue of categorisation he makes these points:
Ms Waugh was at risk of suicide by virtue of her history of self harm, drug abuse and acute psychosis and it was thus appropriate for her to be admitted to hospital.
The frequency with which Ms Waugh was observed by nursing staff was not a crucial variable in the outcome. Rather the key issue was whether she should have been nursed in the HDU. Had she been, the likelihood is that her suicide on 8 January would have been avoided.
"On balance" it was appropriate and in accord with common psychiatric practice for Ms Waugh to have been nursed in the open ward rather than in HDU and for her to be subject to half hourly observations.
Ward 1E maintains a written register which records details of patients confined to the HDU. There is no entry in that document indicating that Ms Waugh was admitted to that unit at any time between 6 January 2008 and the time of her death.
At the time of her initial assessment by Dr Sketcher it was considered appropriate for Ms Waugh to be treated within the open ward and for her to be subject to half hourly observations. This status was maintained, without variation, up to the time of her death. On two occasions Ms Waugh was reviewed by psychiatrists and it was not considered necessary, either to place her in the HDU, or to elevate her categorisation level. The evidence shows mood fluctuations in the days of her admission with episodes of anger, distress and periods of hallucinations. However, there were also periods of calmness. On the day of her death Ms Waugh was cared for by Nurse Farmer in the morning and by Nurse Lee-Archer in the afternoon. Both are experienced psychiatric nurses. Neither observed or detected any sign of intended self harm. When spoken to by Nurse Brooks only minutes before her fateful act Ms Waugh indicated that she was "fine." In my opinion there were no signs demonstrated by Ms Waugh in the several hours immediately preceding her death which should have indicated to those caring for her that she was at heightened risk of self harm and that greater vigilance was required to ensure her safety.
The evidence, including the opinion evidence of Professor Keks leads me to conclude that Ms Waugh’s illness and her overall presentation did not require her confinement to the HDU and that it was, in all the circumstances, appropriate for her to be cared for on the open ward. Furthermore I am satisfied that her categorisation as a level 3 patient requiring 30 minute observations was appropriate.
The evidence shows that despite the nursing staff’s compliance with the level of observation required Ms Waugh was able to take her own life in the period between that last observation made by Nurse Brooks and the time when the next observation fell due.
During her stay in Ward 1E Ms Waugh occupied room number 4. Access to that room is gained by an inwardly opening door. That door is hung upon three closed pin butt hinges which are located on the right hand side of the door when looking outward from the room. As I have already noted it was the evidence of Nurse Lee-Archer that when she entered room 4 on the evening of 9 January she observed Ms Waugh lying behind the door. A blue bed sheet was loosely tied around her neck. She immediately removed the sheet, shouted for assistance and commenced CPR. Nurse Lee-Archer did not, understandably in the agony of the moment, observe a specific anchor point to which the sheet was attached.
In his post-mortem report Dr Lawrence comments; "Autopsy reveals changes consistent with a partial suspended hanging, with petechiae, a fairly broad and indistinct ligature mark and some bruising on the anterior neck. The appearances are consistent with a self inflicted hanging."
I am satisfied that Ms Waugh used her bed sheet as a ligature to hang herself. Although there is no direct evidence on the point, the likelihood is that she utilised the closed door and/or one of its hinges as a means of anchoring the sheet.
Dr Mani Maharajh is a psychiatrist who, at the time of the inquest was Clinical Director of Mental Health Services North. He commenced in that position on 1 December 2008 and had no association with Ward 1E at the time of Ms Waugh’s death. He told the inquest that persons intent on self harm can be very inventive in the means devised to carry out that object. Ms Waugh’s utilisation of the bed sheet and door illustrate that inventiveness and highlights the need for Ward 1E staff to be ever alert to the need, as far as reasonably practicable, to remove any feature within the ward identified as a potential hanging point. I accept that each year a hanging point audit is conducted of Ward 1E. It is my recommendation, as part of that audit process, that specific consideration be given to those means by which the current doors to patient rooms within Ward 1E could be eliminated as potential hanging points and the implementation of those alternative means if reasonably practicable.
Access to Non-Prescription Drugs
Ms Waugh was a known user of illicit substances, notably cannabis and amphetamines. At her assessment on 6 January she confirmed to Dr Sketcher recent use of both these drugs stating to him that she had been "smoking cannabis daily and taking amphetamines fairly regularly." On 8 January a urine sample obtained from Ms Waugh tested negative for amphetamines but was positive for cannabis. Following Ms Waugh’s death toxicology of her blood indicated the presence of cannabis (THC…less than 2 ug/L) and also the presence of methylamphetamine (less than 0.04 mg/L).
Andrew Griffith is a forensic scientist attached to Forensic Science Service Tasmania. It was his evidence that:
Ms Waugh’s post-mortem blood specimen indicated a low concentration of THC.
It is not possible to aver categorically that the post-mortem concentration of THC established that Ms Waugh had used cannabis during her stay in Ward 1E.
If Ms Waugh was a light user of cannabis it is probable that the post–mortem concentration of THC reflected Ms Waugh’s use of cannabis during her hospitalisation. However, if she was a chronic cannabis user it is more probable that her last ingestion of that drug occurred prior to her hospital admission.
The reported half life of methylamphetamine (ie the time it takes for the drug to reduce its blood concentration by half) is between 5 and 15 hours.
It is possible for the methylamphetamine detected after post-mortem to have been ingested prior to Ms Waugh’s admission to hospital. However, for this to occur Ms Waugh’s blood methylamphetamine concentration at the time of her admission would have to have been very high, probably greater than 1 mg/L. On this basis it is more probable that Ms Waugh consumed methylamphetamine whilst she was in Ward 1E.
In some circumstances post-mortem testing of blood can detect methylamphetamine in low concentrations which would not be detected by testing of urine.
It was the evidence of Professor Keks that ongoing use of amphetamines and/or cannabis can worsen a patient’s psychosis causing increased delusions, hallucinations, disordered thinking and mania. Impulsivity is also likely to increase. Further, continuing use of illicit drugs during treatment is likely to cause decreased efficacy of antipsychotic medication.
I am not upon the evidence able to make a positive finding that Ms Waugh did ingest either cannabis or methylamphetamine in the period of her stay in Ward 1E. However, the results of the post-mortem blood testing raise the possibility that she did so and this is particularly the case with methylamphetamine. Obviously it is important, as Professor Keks makes clear, that persons suffering a psychosis be denied access to these illicit substances because of their capacity to worsen symptoms and to compromise treatment. Did Ward 1E have in place practices and procedures to best ensure that such access was denied? This question gives rise to several issues which I will address in turn. They are:
Searching patients on admission.
Visitors to the ward.
Preventing public access to the ward’s external courtyard.
Searching Patients on Admission
There was no direct evidence on whether Ms Waugh’s clothing and other possessions were searched at the time of her admission to Ward 1E. However, Dr Alempijevic said that it was "standard practice," at the time of admission, for a patient’s belongings to be searched for illicit substances. According to Professor Keks a search of a patient’s belongings at this time would be "fairly routine." Nurse Szolna said that it was her own practice to check a patient’s belongings at the time of admission and if the patient did not co-operate or she suspected was concealing dangerous goods or illicit substances then she would have a doctor talk to them. She acknowledged a concern that in some instances patients may be admitted with drugs on their person which they can subsequently use. Dr Maharajh agreed that it was desirable for a patient’s belongings to be searched on admission but was unsure of the steps that could or should be taken to affect that search saying "it’s not something that I’ve given my mind to." Further, the tenor of Dr Maharajh’s evidence on this subject suggested that in his view the power to search a patient’s belongings may differ depending on the voluntary or involuntary status of that patient.
Overall, the evidence on this topic suggests to me that the staff of Ward 1E staff at the time of Ms Waugh’s death considered it desirable for a search to be made of a patient’s belongings on their admission and that such searches are ordinarily taken, most particularly, I suspect, in those instances where a patient is presenting because of drug abuse or has a known history of drug misuse. However, the evidence also indicates to me that there exists considerable uncertainty on what steps can or should be taken in those instances where a patient refuses to agree to a thorough search of his/her belongings. This is an issue which may involve considerable legal complexity. Nevertheless, it is sufficiently important to warrant consideration and the formulation of clear guidelines for staff’s use. It is my recommendation that this be undertaken.
Visitors to the Ward
Visits by family members or friends can present as an obvious opportunity for patients on Ward 1E to access illicit substances.
The evidence shows that neither the visitors to Ward 1E nor their belongings are searched for drugs. Visiting hours are from 2.00pm to 8.00pm although some flexibility is permitted. There is no practice to record the attendance of visitors. Access to Ward 1E is gained via doors which, according to Ms Jeanette Dorman, the Nurse Unit Manager of Ward 1E, "are routinely kept closed." At one time the doors were opened by key but more recently a "swipe" system is used. It is not clear on the evidence whether the latter system was in place at the time of Ms Waugh’s death.
It was the evidence of Ms Waugh’s mother that on each occasion she visited her daughter during her last admission the doors to the ward were open and she was able to gain immediate access. I accept this evidence. It only confirms that Ward 1E did not operate as a "locked ward" as described by Ms Dorman although the ward may be "routinely" closed.
When asked about patients accessing drugs via the open courtyard Ms Dorman gave this evidence upon access to drugs generally;
"…it’s no easier to access drugs from the courtyard as it is from, in the middle of the ward. Because, people bring drugs in and give them to patients. We had a guy yesterday that handed over some marijuana. We can, if we know about it, we act upon it. We call the police. We do all the right things, but, to stop it we would have to operate like a prison, and I mean drugs get into prisons. ………………….if someone was thinking about trying to get drugs onto the ward to a specific person, they would probably just bring them in and hand them over and no-one would be the wiser. I mean that’s, that’s (sic) unfortunate, but other than you know, as I said, make it like a prison and I can’t see that happening because our philosophy is less restrictive. So to do that would just destroy that whole philosophical basis really."
As Professor Keks observes, "the prevailing ethos in Australia in public psychiatry is that patients should be treated in the least restrictive environment." However, this situation gives rise, again as Professor Keks states to "enormous difficulties…..from the conflict between the need for safety and security, and the aim of providing humane treatment in the least restrictive setting."
Ward 1E operates in a largely unrestricted environment which accords with that "prevailing ethos"as described by Professor Keks. There has not been any evidence which urges the adoption of a more restricted environment for the care and treatment of those patients who do not require management in a facility such as HDU and I do not recommend that a more confining option be considered.
However, it is concerning when the Ward’s Nurse Unit Manager, on the one hand states that "we do all the right things" to prevent visitors bringing drugs onto the ward but at the same time acknowledges that a visitor could "probably just bring (drugs) in and hand them over and no-one would be the wiser." This situation, in my view, requires a re-assessment of the procedures relating to visitors to the ward, particularly for visitors to patients who have a known history of drug abuse. Such re-assessment should aim to identify those means by which patient access to illicit drugs can be made more difficult without needing to resort to a lock-down environment akin to a prison. It is my recommendation that such a re-assessment be undertaken and its recommendations adopted.
Ward 1E is designed so that it opens onto an external courtyard. The courtyard is fenced but the grounds beyond are accessible by members of the public. As a consequence it is quite feasible for a patient within the courtyard to receive illicit drugs from a person outside its fence. Dr Gruebl described the courtyard as a "weak point" and stated further; "I could see from my office contacts from clients via the side especially the door to the street. Here I can imagine drug trafficking may have happened."
I accept that the courtyard is an amenity of Ward 1E which significantly benefits its patients and it is thus important that they be able to utilise it. However, it is also important that it not be utilised for illicit purposes. It is thus my recommendation that a review of the courtyard and its surrounds be undertaken with a view to eliminating it as "weak point" in the ward’s defences against the delivery of unwanted drugs or other materials.
Patient Telephone Use
It was the evidence of Ms Dorman that:
Ward 1E does not have any protocols in place concerning patients making or receiving telephone calls.
A public telephone is located in the hallway of Ward 1E which can be used by both patients and visitors for outgoing calls.
A telephone is sited in the dining room which can be utilised by patients for both incoming and outgoing calls. During office hours incoming calls are ordinarily transferred to this ‘phone from a ‘phone located in the ward clerk’s office. Outside of office hours the calls are transferred from a ‘phone in the nurses’ station.
That patients have a right to maintain contact with the outside world and this right would be infringed if they were denied access to a telephone. However, it would be in order to deny a patient use of a mobile ‘phone if he/she was admitted to HDU.
If it was observed that a patient was receiving calls that were causing him/her distress then it would be suggested that their mobile ‘phone be surrendered but staff would not insist that this occur in the face of patient resistance.
On 6 January Ms Wright spoke to her daughter by ‘phone. As I have already recorded the call was followed by a "shouting outburst," as observed by Nurse Ashton, and then Ms Waugh threw a cup of coffee onto the ceiling.
In the morning of 7 January Ms Waugh had a ‘phone conversation with Mr Harrison. Shortly afterwards he visited her and delivered some clothing. After that visit Nurse Freeman has noted in the Progress Notes; "Claire asked him not to return." Later that same morning Ms Waugh spoke to her mother on the ‘phone. It was the evidence of Nurse Freeman that both these calls distressed Ms Waugh and after each of them "she required prn medication to help her settle." However, later that day Nurse Lee-Archer recorded that Ms Waugh responded positively to ‘phone contact with her children.
It was the evidence of Ms Wright that in the morning of 8 January she telephoned Ward 1E and spoke to a staff member. She asked how her daughter seemed that day. She also asked whether she had had any calls from "Damien," the father of her children and/or his mother and whether she "had spoken to the girls." She was told "Yes" and that "she was getting worse after each call from Damien." Ms Wright explained that there had been a history of violence involving her daughter and Damien and she was concerned that his calls were "stopping her from getting better." She asked whether the calls could be monitored to ensure that Ms Waugh only spoke to her children and not to Damien or his mother. She was advised that "they didn’t have the time or the resources to do this." Later that same day Ms Wright spoke to Damien’s mother by ‘phone who acknowledged that she had had an argument with Ms Waugh. I accept Ms Wright’s evidence upon these matters.
I have noted earlier in these reasons that on 9 January Ms Waugh again spoke to her children by ‘phone and, according to Nurse Farmer, she "enjoyed this contact."
In statements made for the inquest Dr Gruebl states; "I was seriously concerned about (Ms Waugh) receiving distressing telephone calls in her initial acute phase of treatment, where patients are very irritable and not able to cope with the stress of any confrontation. In an acute psychotic phase the ability of processing any information is heavily impaired and therefore a low stimulus environment is crucial." Dr Gruebl further says; "A learning point of it could be to find ways of preventing clients from distressing telephone calls and working on optimizing a low stimulation environment for higher psychotic and distressed clients."
Professor Keks expressed the view that only in "extreme circumstances" would restrictions on telephone use be included as part of a patient treatment plan. This was on the basis that "one would be very concerned about any implication that you’re keeping, you’re infringing communication where that’s desired." However, he acknowledged that in those instances where a patient became particularly distressed following a telephone call that "there should be a debriefing, there could be an intervention such as the patient may nominate people they won’t talk to."
Professor Keks further made the observation that in the private hospital where he currently works mobile ‘phones are banned from patient use on the basis that "in a private hospital everyone is there….because they want to be, when they’re not it changes the balances."
Comments and Recommendations
As explained earlier in these findings, I accept that it was appropriate for Ms Waugh to have been treated in the open ward rather than being confined to HDU. However, she was seriously ill and her condition necessitated, to adopt Dr Gruebl’s words, a "low stimulation environment." The evidence shows that within the first 48 hours of her admission she became distressed when receiving ‘phone calls and that her distress was sufficiently serious to require additional medication. The only response taken by staff to manage the adverse affect of external contact with Ms Waugh was for Nurse Freeman to record in the Notes that she did not wish for a return visit from Mr Harrison.
I recognise that there is a prevailing ethos within psychiatric facilities that patients have an entitlement to receive visitors and to make and receive telephone calls. I accept that this entitlement is in accord with a patient’s basic human rights and ordinarily is beneficial to his/her treatment and recovery. However, this entitlement is not absolute and must be weighed against the care and safety of the patient and at times the safety of others. It is self-evident that strict controls regulating third party contact needs to be in place for those patients whose illness necessitates confinement in a facility such as the HDU. In the case at hand, Ms Waugh was being cared for in the open ward but her illness, most particularly in its acute phase, required the maintenance of a low stimulus environment. Such an environment could not, in my view, be assured when she, in effect, was treated like all other patients in the open ward and exposed to unmanaged and uncontrolled interaction by telephone with persons from outside the ward. This situation leads me to recommend that those persons responsible for the operation of Ward 1E give consideration to devising and putting in place a protocol requiring the adoption of a plan to maintain a low stimulation environment for those patients whose illness makes it necessary. Such plan should include techniques by which telephone contact with the patient should be managed.
The evidence does not permit me to make a finding that Ms Waugh’s exposure to telephone calls was a factor which contributed to her death. In this context it is relevant to note that the only telephone call that Ms Waugh had on the day of her death was with her children and that this was observed to be a positive experience for her.
Responses to Emergency Situations on the Ward
It was the evidence of Nurse Austin that she responded to a request for the ward’s emergency resuscitation equipment and delivered it to Ms Waugh’s room. She said that it was contained in a large red bag which was "heavy." She attempted to assemble the equipment but it could not be "connected" and she realised a different oxygen cylinder was required. She was able to obtain such a cylinder from another room but when she returned the Code Blue team had arrived and were utilising its own equipment. The evidence shows that in the period between Ms Waugh being discovered on the floor of her room and the arrival of the Code Blue team nursing staff maintained CPR.
It was the evidence of Ms Dorman that since Ms Waugh’s death an "emergency kit" has been acquired for Ward 1E. It is maintained on a trolley which is kept in the ward’s Drug Room. Ms Dorman explained that the kit is checked by a staff member each day and a register maintained to record the checks.
It is unfortunate that Ward 1E did not have immediate access to resuscitation equipment when Ms Waugh was found by Nurse Lee-Archer. However, the evidence shows that the Code Blue team arrived relatively promptly and took over the resuscitation which had been maintained by nursing staff in the meantime. The evidence does not permit a finding that the immediate unavailability of properly functioning resuscitation equipment was a factor which contributed to Ms Waugh’s death.
Quality Assurance Committees and the Health Act 1997
S4(1) of the Health Act 1997 provides for the establishment of approved quality assurance committees. By s1(3) any member of a committee may not divulge or communicate to any person any information gained as a committee member except to the extent necessary for the performance of the functions of the committee and by ss1(6) any information or document prepared for the purposes of a committee is not admissible in any action or proceedings in any court.
Professor Mark Oakley-Browne is the State-wide Clinical Director for State-wide Mental Health Services in Tasmania. It was his evidence that the Department of Health & Human Services convened a Serious Incident Sub-Committee to investigate the circumstances of Ms Waugh’s death. That investigation included a Root Cause Analysis. It was the further evidence of Professor Oakley-Browne that such Sub-Committee had been declared a quality assurance committee within the meaning of Section 4 of the Health Act 1997 and as such was governed by those confidentiality provisions which I have set out. Professor Oakley-Browne explained the rationale for quality assurance committees being able to conduct their business protected by total confidentiality in these terms;
"Principally such confidentiality means that it is more likely that those involved in an incident being considered by a Quality Assurance Committee will talk openly and freely without fear of any statements made being used to establish liability or to lay blame."
"That approach is appropriate because the purpose of the Committee is not to establish any liability or to establish any fault or lay any blame or even necessarily look for causal relationships, but to ensure improvements in health care. That is more likely to be achieved where there can be a full and frank discussion without fear of any adverse consequences. Confidentiality is the only way of achieving that."
It was the personal view of Professor Oakley-Browne that there currently exists among health professionals "significant attitude and cultural issues" which will have to be addressed before those professionals will be comfortable in contributing freely to the investigation of adverse hospital incidents without the protection of the confidentiality provided by Section 4 of the Health Act 1997.
Because of the confidentiality provisions Professor Oakley-Browne was unable to give evidence at the inquest of any information which may have been received by the investigating Sub-Committee, nor was he able to report upon the content of any recommendations which may have been made arising from the Sub-Committee’s investigation.
It was the unchallenged evidence of Ms Dorman that she was unaware of any committee having undertaking any quality assurance investigation of the circumstances of Ms Waugh’s death. It was her view that if any such investigation had taken place then she should have been asked to give evidence to it. It was her further evidence that any recommendations which may have been generated by such a committee had never been brought to her notice. Further, it was the evidence of Ms Waugh’s mother, which I accept, that although she was aware of an internal investigation into the circumstances of her daughter’s death she had not received any information as to the outcome of that investigation nor had she been advised of any recommendations which may have been made by it.
I am aware from my own knowledge that in 2010 a review of the confidentiality provisions attaching to quality assurance committees was undertaken at the behest of the Department of Health and Human Services and that amending legislation designed to relax those provisions is being contemplated.
Comments and Recommendations
A coroner has a statutory obligation to establish how, why and when a person died and, when appropriate, make recommendations upon ways of preventing further deaths and also, where appropriate, make comment upon any matter connected with the death including maters related to public health. There is an expectation, I believe, both on the part of the family of a deceased person and on the part of the community generally that the coroner will have access to all relevant information which enables him/her to fulfil these obligations. Any obstruction to that access brought about by resort to s4 of the Health Act 1997 has, in my view, the potential to undermine public confidence in the integrity of public health administration and in the capacity of the coroner to meet his/her statutory duties. The need for there to be absolute transparency and unfettered disclosure is particularly necessary, in my opinion in those cases, as has occurred here, where the death involves a person involuntarily detained in a secure mental health unit pursuant to the provisions of the Mental Health Act 1996.
The foregoing leads me to support any move to legislate for a revision of the confidentiality provisions which attach to quality assurance committees so that the coroner has unfettered access to all information received by such a committee in the course of a death investigation including any recommendations which may follow from its deliberations. I acknowledge that there may exist, as Professor Oakley-Browne has identified, "attitude and cultural issues" on the part of some health professionals in the public sector which may make them reluctant to participate in committee investigations if unprotected by confidentiality provisions. It is thus my recommendation that any steps to remove the confidentiality provisions be accompanied by the implementation of a programme to educate all medical professionals upon the need for and the benefits of their participation in the investigation of all adverse medical deaths and that they be conducted in a totally open and transparent environment.
Before leaving this subject I need to comment upon an aspect of the Serious Incident Panel’s investigation of Ms Waugh’s death. The thoroughness of that investigation and its worth as a means of identifying any systemic failings contributing to the death and implementing any changes to address those failings must be seriously questioned when Ms Dorman, as the person in charge of Ward 1E’s nursing services, was unaware that an investigation had been conducted, was not invited to participate in it and was not informed of those recommendations which had apparently arisen from its deliberations. These circumstances lead me to recommend that Mental Health Services review its utilisation of serious incident panels to better ensure the quality and value of their work.
Findings and Report Required By S28(1) And (5) of the Act
I formally find that Claire Louise Waugh, born 10 August 1985, died in Ward 1E of the Launceston General Hospital in Launceston on 9 January 2008. I further find the cause of death to be hanging following methylamphetamine use. I am satisfied and find that Ms Waugh’s death was facilitated by use of a bed sheet anchored to her room door or a hinge on that door. I find too that Ms Waugh’s death was the consequence of an intentional act on her own part and that no other person contributed to it.
The death of a young person by their own hand is a tragic event and this is particularly so when it involves a young person and in this case a mother. I am unable to make any findings upon the reason for Ms Waugh acting as she did. The evidence suggests that it was an impulsive act without any sign of pre-planning. It occurred at a time when she was unwell and had been having difficulties maintaining contact with her children. It is possible that in the context of these matters she considered the pain of living too difficult to bear.
S28(5) obligates me to report upon the care, supervision or treatment of Ms Waugh whilst she was a person held in care within Ward 1E. This leads me to formally find that I am satisfied that by reason of Ms Waugh’s mental illness it was appropriate for her to be detained as a involuntary patient in Ward 1E pursuant to the provisions of the Mental Health Act 1996. In a general sense I am also satisfied upon the evidence that the care and treatment afforded to Ms Waugh whilst a patient in Ward 1E was proper and appropriate. However, I have sought in these findings to identify some areas where improvements can be made in the care and treatment of patients who present in circumstances similar to Ms Waugh.
I conclude by extending my sincere condolences to Ms Waugh’s family.
Dated at Launceston in the State of Tasmania this 29 day of September 2011.