FIND THAT :
David Nicholas ASSMANN (“Mr Assmann”) died on 17 February 2005 within the precinct of the Royal Hobart Hospital (“RHH”) at Hobart.
Mr Assmann was born in Hobart on 15 June 1967 and was aged 37 years at the date of his death. He was a cabinet maker and a divorcee.
I find that Mr Assmann died from multiple chest and abdominal injuries suffered when he jumped from a window on level 4 of the RHH. At the time of his death Mr Assmann was in the care of medical practitioners at RHH.
Mr Assmann had a lengthy psychiatric history beginning in 1987 when he was admitted to a hospital in Queensland and diagnosed with schizophreniform psychosis. In 1990 he suffered a relapse and was then diagnosed with paranoid schizophrenia. Thereafter, Mr Assmann’s illness demonstrated a pattern of remission and relapse. During periods of remission he showed good functioning with ability to return to work and form relationships. During times of relapse, Mr Assmann was often admitted to the RHH, (in all he had 14 admissions). The severity of his symptoms and insight varied during these admissions. Some required him to be involuntarily detained pursuant to the Mental Health Act 1996 whilst others could be managed with Mr Assmann being a voluntary patient. His main symptoms revolved around auditory hallucinations, persecutory themes and being preoccupied with religion. At times he could be aggressive and threatening but as his psychosis settled he would be usually pleasant and co-operative. He received an extensive range of psychiatric treatments.
In 1999 he commenced taking clozapine dispensed by the clinic at RHH. However, in 2002 Mr Assmann ceased taking this medication and thereafter his mental state deteriorated. His marriage failed and he found it difficult to find work in his trade as a cabinet maker. He then took on a position as a security guard at the Tahune Airwalk but in December 2003 lost this job when, acting under a paranoid delusion, he locked patrons in a reception area when he believed that they were under threat of attack. Mr Assmann was again admitted to RHH following this event.
From about August 2004 the Southern Tasmania Community Mental Health Service with the Crisis Assessment, Triage and Treatment (CAT) team became involved in Mr Assmann’s care and Dr Patricia Bryant assumed management of his mental illness. Just prior to Christmas 2004 Dr Bryant believed Mr Assmann sufficiently well for him to be challenged about his memories and mental experiences of the incident at Tahune Airwalk 12 months previously. They were able to discuss these matters without Mr Assmann exhibiting any signs of hyper-sensitivity, hostility, guardedness, evasiveness, paranoia or undue anger. Plans were put in place for Mr Assmann’s referral to a rehabilitation service in the New Year. In mid January 2005 Mr Assmann continued to appear well. However, by early February Mr Assmann’s mother was concerned about his mental state. Dr Bryant visited him at home on 7 February. He told her of some hallucinatory experiences which he said were more like “murmurings”. Nevertheless, he appeared to be still alert, bright and reactive in demeanour and able to take part in a discussion about medication and a proposal for a respite admission to Tolosa Street Residential Rehabilitation Unit. Arrangements were put in place for admission to take place on 14 February. He was seen two days prior to this by a CAT team member and he explained on this occasion more explicitly that he was hearing voices. When admitted to Tolosa Street on 14 February Mr Assmann described experiencing panic attacks. The next day police officers reported to Tolosa Street staff that Mr Assmann had been to the Glenorchy Police Station to give them information about his beliefs as to what he thought had happened in the Tahune Airwalk incident over a year previously. This was reported to Dr Bryant. That afternoon Mr Assmann began to display bizarre behaviour described as “sprinting to the front gate and then ducking down behind the fence”. Dr Bryant by this point was concerned that Mr Assmann did not appear to be responding to an increase in his dosage of oral risperidone. She also had concerns that he had been using cannabis, other drugs or alcohol and that he may not have been taking the risperidone as prescribed. Accordingly, arrangements were put in place for Mr Assmann to be admitted to the Department of Psychological Medicine (DPM) at RHH.
In Dr Bryant’s opinion explicit suicidal ideation had not been a feature of Mr Assmann’s presentation throughout the time she had known him. In contrast, although at times he seemed frustrated and impatient with the impact of his illness and its treatment, he was able to formulate goals and plans for his future, although they may have been somewhat overly optimistic.
Mr John Fahey is a psychiatric nurse and a member of CAT. He had had regular contact with Mr Assmann from June 2004 up to the time of his final admission to RHH in February 2005. Mr Fahey says that at no time had Mr Assmann presented to him as being depressed. He says that he never voiced any thoughts of self harm or suicide nor did he describe command hallucinations to harm himself.
On 16 February 2005 Mr Assmann was admitted to DPM following a clinical examination. He was admitted as a voluntary patient on a Category 3 status which meant that he was to be sighted by a nursing staff member on an hourly basis and could not leave the ward unless accompanied by a responsible adult. The following morning Mr Assmann was interviewed by psychiatrist, Dr Phillip Reid with Psychiatric Registrar, Dr John Madden. Dr Reid had treated Mr Assmann during previous admissions. On this occasion Mr Assmann repeated his history of hearing murmurings within his head but he could not discern voices. He admitted being stressed from the Airwalk incident and that he was currently without accommodation. He talked of some plans for the future which included resuming his cabinet making. He reported some restlessness. He indicated that he was happy to continue the depot injection of risperidone and was happy for his oral medication to be reviewed to assist in reducing his auditory hallucinations. Neither doctor detected any indication of self-harm. It was Dr Reid’s impression that Mr Assmann was suffering a psychotic relapse but in contrast to previous admissions had good insight and appeared happy to co-operate with the admission to hospital and to consider alternative medication. Dr Reid has observed that self-harm, threats of suicide and suicidal ideation had not previously been features of Mr Assmann’s illness and on this occasion he did not voice any idea of suicide. Dr Reid did not believe that there was any indication to change Mr Assmann’s category status.
In the afternoon of 17 February 2005 the two exit doors to DPM were locked because of concerns that two patients may abscond. During that afternoon Mr Assmann was noted to be on his bed resting at the time of each hourly observation check. His interaction with nursing staff was appropriate. He appeared settled and not in any distress.
Nurse Annette Price and Nurse Maxine Wilton were on roster for DPM’s afternoon shift on 17 February. Sometime between 5.30 and 5.45pm they both noted that the north door to DPM was propped open. Nurse Price went to close the door and as she did so Mr Assmann walked back into the ward through the door. It was evident that Mr Assmann had been able to exit the ward despite its lock-down status. Nurse Price told Mr Assmann that his evening meal had arrived. Shortly afterwards both Nurse Price and Nurse Wilton proceeded to dispense the evening medications. They could not find Mr Assmann in the ward. Nurse Price went outside to the front of the hospital to try and locate him. She was unsuccessful.
Ms Angela Russell is a nurse employed in RHH’s Day Surgery Unit located on the fourth floor of A Block. She finished her shift at 5.45 pm and proceeded to leave the ward via the stairwell. As she opened the stairwell door she observed a male descending the stairs who appeared agitated. She asked him, “Are you ok?”. He replied, “I need to get out of here. I just want to get out of here”. Nurse Russell told the man that he was on the fourth floor and that if he went with her she would take him down the stairs to the lower ground floor where he could leave the building. The man went with her down the stairs to the third floor and then went to open a door to exit the stairwell. Nurse Russell told him that the door would only take him to another ward and that if he stayed with her she would make sure that he got downstairs and out of the building. The man again said, “I just want to get out”. He then went through the door onto the third floor. Nurse Russell proceeded down the stairs to the second level. After this she heard two banging noises above her.
Professor David Kilpatrick is a cardiologist employed at RHH. At about 5.50 pm on 17 February 2005 he drove his motor vehicle from Campbell Street intending to park it in a parking area within the precinct of RHH. As he approached the parking area he noted glass on the ground. He stopped his vehicle and got out intending to sweep the glass aside with his foot. At this moment he heard a male voice from above. He looked up and saw a male leaning out of a hospital window. That person said, “Get out of the way” and then launched himself out of the window landing on the ground in front of Professor Kilpatrick. He immediately attended the male person. It was obvious that he had sustained serious injury and help was sought from the hospital. The male person, who was later identified to be Mr Assmann, was taken to RHH’s Department of Emergency Medicine. He was pronounced dead at 6.36 pm.
Officers of Tasmania Police attended at the scene of the incident and later carried out an investigation of Mr Assmann’s death. They were satisfied that there were not any suspicious circumstances surrounding the death.
I am satisfied that Mr Assmann died from injuries suffered when he jumped from a level 4 window of RHH onto a car park below. I am also satisfied that there are not any suspicious circumstances surrounding this death.
Mr Assmann was a long term sufferer of paranoid schizophrenia and at the time of his death had been a voluntary admission to DPM following a deterioration in his condition. He was classified as a category 3 patient. I am satisfied on the evidence that this category was appropriate.
Mr Assmann’s actions in absconding from DPM, ascending the stairs to level 4, breaking a window and then launching himself through the window onto the car park below are all consistent with a finding that he intended to take his own life. However, during the course of his illness signs of self-harm, threats of suicide and suicidal ideation had not been part of his presentation. On the day prior to his death neither of the examining doctors detected any signs suggestive of suicide. It seems that the deceased did not leave a suicide note. All of these matters are contra-indicative of suicide. I have noted the evidence of Nurse Russell which clearly indicates Mr Assmann to have been agitated, confused and anxious, if not desperate, to escape the building. This evidence is suggestive that Mr Assmann, in his mentally disturbed state, may have been seeking to escape unnamed and delusional persecutors. In the result, whilst I am satisfied that Mr Assmann did intend to exit the hospital via a 4th floor window, I am unable to determine on the evidence whether this act was motivated by the desire to take his own life or by other cause.
As I have already noted Mr Assmann’s death occurred when its two exit doors had been locked because of a concern that two patients may abscond. Despite this it is evident that Mr Assmann had been able, on two occasions, to escape the ward. The investigation has not been able to establish how this was achieved. This is a matter of concern because it is clearly necessary at times for DPM to be made secure for the safety of its patients and others. There is a need, and I so recommend firstly, that a security review be undertaken of DPM both to identify any potential weaknesses in the ward’s capacity to contain its patients and to advance cost-effective and practical proposals to overcome those weaknesses and secondly to implement those proposals.
There is a matter of particular concern arising from this death. When a patient dies in circumstances which makes the death reportable to the coroner it is common practice for RHH to direct a Serious Incident Panel to carry out an internal investigation of the death and its surrounding circumstances. This occurred in the case of Mr Assmann. Subsequently, the Chief Executive Officer of RHH wrote to the Coroner’s Office and reported that as a result of the Panel’s investigation it appeared that Mr Assmann’s death may have resulted from injuries accidentally sustained rather than being the consequence of an intentional act of self-harm. The Coroner’s Office then made a request of RHH for it to produce that evidence which caused the Panel to reach this conclusion. Such evidence has not been forthcoming. However, I make no criticism of RHH for this non-production for the reason I can now explain.
Section 4 of the Health Act 1997 (“the Act”) provides for the establishment of quality assurance committees. The provision makes it an offence for any member of such a committee, either directly or indirectly and except as is necessary to perform the functions required of a committee member, to make a record of, or divulge or communicate to any person, any information gained by or conveyed to that person as a committee member. Further the section provides that a committee member is not required to divulge or communicate to any court any matter or thing coming to his notice as a committee member nor is any document or information which relates to the proceedings of a committee admissible as evidence in any court.
I am advised that Serious Incident Panels, established by RHH to investigate reportable deaths or other adverse medical outcomes, have been declared to be quality assurance committees within the meaning of s4 of the Act and are thus subject to those matters mentioned above. This explains why RHH has not produced the requested evidence to the Coroner’s Office for to do so would, prima facie, constitute an offence. This is therefore my reason for not being critical of RHH upon this issue.
I can understand that those statutory prohibitions protecting the release of information received by a Serious Incident Panel may, in some circumstances, encourage persons who may otherwise not do so, to come forward and provide evidence. This is laudable because it is obviously critical to a Panel achieving its purposes that it gains access to all information relevant to the matter under investigation. However, in cases involving death, the legislation in its current form has, in my view, an undesirable and perhaps unintended consequence as illustrated by the coronial investigation of Mr Assmann’s death. Here, as I have explained, RHH has been prevented, because of s4 of the Act, from making available to myself all of the evidence received by its Serious Incident Panel, evidence which may be critical to my coronial findings because it seems to have inclined the Panel to the view that Mr Assmann’s death may have been accidental rather than an act of suicide. This in my view is a most regrettable circumstance. It is my recommendation that a review of s4 of the Act be undertaken as a matter of urgency with a view to implementing changes which would enable a coroner to have unrestricted access to all material and information received by a Serious Incident Panel in its investigation of a death occurring in a hospital setting.
I conclude by extending my sincere condolences to Mr Assmann’s family.
Dated the 29th day of May 2006.