In The Matter of The
Coroners Act 1995

And

In the Matter of an Inquest
Touching the Death of
JAKYUNG SEO LYALL

FINDINGS, RECOMMENDATIONS AND COMMENTS of Coroner Rod Chandler following an inquest held in Hobart.

EXECUTIVE SUMMARY

1. Mrs Jakyung Seo Lyall was born on 28 October 1974 and was aged 31 years.

2. Mrs Lyall died at about 7.30 pm on 19 October 2006. Her death occurred in a bathroom of the Detoxification Unit operated by the State's Alcohol and Drug Service located in the Carruthers Building at St Johns Park in New Town.

3. The death occurred as a result of Mrs Lyall intentionally hanging herself with an electrical cord from a shower curtain rail. I formally find the cause of death to be hanging during treatment for alcohol and benzodiazepine withdrawal.

4. In September and October 2006, being the periods relevant to this inquest, the Detoxification Unit had not been declared a treatment centre as required by the Alcohol and Drug Dependency Act 1968. It accordingly did not qualify as a place where any person, including Mrs Lyall, could be lawfully detained against their will under the provisions of that Act. Any representation made to Mrs Lyall that she was obligated to remain in the Unit, that she was required to comply with any conditions attaching to a leave of absence, and that she could be recalled to the treatment centre upon revocation of any leave were all illegitimate and without legal foundation.

5. For those periods when Mrs Lyall was detained in the Detoxification Unit no person had been appointed as Superintendent of that Unit as required by the Act. It follows that neither Dr Clayton nor any other medical practitioner was empowered at that time to exercise those powers under the Act vested in the Superintendent. This included the power to detain Mrs Lyall.

6. The failure to ensure that the Unit was declared a treatment centre and that Dr Clayton was appointed its Superintendent as required by the Act arose from administrative oversight and was unintended. This state of affairs reflects poorly on the competence of those persons who had the responsibility for administering the Act and ensuring compliance with the law.

7. At the time of her death Mrs Lyall did not qualify as a person held in care or a person held in custody as those terms are defined by the Coroners Act 1995. It follows that this is not an instance where I am mandated to report upon Mrs Lyall's care, supervision or treatment under Section 28(5) of the Coroners Act 1995.

8. Mrs Lyall had a severe and chronic dependence upon alcohol, she appeared unmotivated or unable to embrace treatment and she presented a very serious medical challenge if her life was to be saved from the consequences of her addiction.

9. The only service the Detoxification Unit was able to offer an involuntary alcoholic patient was detoxification involving denial of alcohol and management of the withdrawal process with drugs and nursing support and little more.

10. The Detoxification Unit did not have the capacity to provide patients suffering from intractable alcoholism such as Mrs Lyall with the standard of treatment which their condition required and which they and their families were entitled to expect. I accept that the level of care available to Mrs Lyall was "B Grade" as described by Professor Jon Currie.

11. The treatment plan embarked upon at the time of Mrs Lyall's first admission to the Detoxification Unit, being confined to detoxification followed by a discharge which was largely unplanned and unmonitored and conditional on abstinence, was in my view grossly inadequate and unlikely to be of any benefit. To settle on this course of treatment was an error compounded by its repetition when Mrs Lyall was re-admitted following the inevitable breach of the non drinking condition.

12. Mrs Lyall's care and treatment required, at the time of her first admission, a management plan which, in the least, incorporated:

• A course of detoxification with pharmaceutical support.
• The securing of a full history of Mrs Lyall's illness.
• The convening of a case conference involving all interested parties to settle on a plan for Mrs Lyall's treatment, both as an in-patient and after discharge.
• A resolve for Mrs Lyall not to be discharged until a firm plan was in place for her care and treatment post detoxification.

13. It would, in my view, be inappropriate in the circumstances to make a finding that the nursing staff had contributed to Mrs Lyall's death.

14. The deficiencies in the level of care provided by Dr Clayton were almost entirely a consequence of systemic failings within the Unit. In this circumstance it would not, in my view, be appropriate to make a finding that Dr Clayton contributed to Mrs Lyall's death.

15. The revolving-door form of treatment provided to Mrs Lyall, in all probability, caused her an increased level of anxiety and depression. However, I am unable to find that this was the trigger, when considered in the light of her entire medical and social history, which caused her to take her own life. I am satisfied, nevertheless, that the Alcohol and Drug Service did by its provision of sub-standard care to Mrs Lyall deny her that 60% or thereabouts chance of being successfully treated which Professor Currie's evidence showed was reasonably achievable.

16. It is my recommendation that the Alcohol and Drug Service put in place a formal procedure designed to ensure that as soon as reasonably practicable a full medical history be obtained upon an involuntary patient's admission to the Unit. Such procedure should include the need to be fully informed upon the patient's previous treatments and may require communication with family members and other medical treaters.

17. It is further recommended that the Alcohol and Drug Service adopt a practice to ensure that patients involuntarily admitted to the Detoxification Unit undertake, within 48 hours of each admission, a formal psychological assessment to be carried out by a medical officer or properly trained nurse.

18. It is a further recommendation that the Detoxification Unit have assigned to it a psychiatrist, available on an as needs basis to provide psychiatric services for its patients.

19. It is further recommended that the Alcohol and Drug Service put in place procedures to ensure the development and utilisation of a comprehensive treatment plan for each patient involuntarily admitted to the Detoxification Unit. Such plan should incorporate the timely convening of a case conference involving all interested parties, the adoption of an in-patient plan for management of the patient's treatment and care and the development and adoption of a post-discharge plan providing for the patient's on-going treatment and its monitoring.

20. Evidence was received at the inquest that since 2006 the Alcohol and Drug Service had received a significant increase in funding which had enabled it to develop and implement procedures within the Unit, to recruit personnel including a psychologist and counsellors and to improve its access to out-patient counselling services. However, it is my further understanding that no steps have been taken to evaluate the effect of these changes upon patient-care and whether improved outcomes are being achieved. It was the evidence of Professor Currie that the unit under his management at St Vincent's Hospital aims to achieve for its patients a 60-70% abstinence from alcohol at five years post-detoxification. It is my recommendation that a similar standard be set for the Unit and that its performance be evaluated annually against that standard.

21. This inquest has necessarily been focused upon Mrs Lyall's care and treatment by the Unit. However, her medical history shows that prior to September 2006 she had sought treatment for her addictive illness in several other facilities, both public and private. A scanning of their records would indicate that none put in place a treatment regime incorporating those ingredients advised by Professor Currie. It is my recommendation that each of those facilities review their practices and procedures for the treatment of alcoholics and give consideration to incorporating those principles advised by Professor Currie.

22. It was the tenor of the evidence provided by Dr Reynolds that the standard of treatment recommended by Professor Currie, whilst in many respects desirable, was unattainable because of budgetary limitations. This is unacceptable. The alcohol industry, with all of its components, is a source of vast profits in this country. It also generates significant excises and other taxes. It is beholden upon the industry, governments and the community generally to ensure that properly funded and resourced facilities are available in this State to properly treat those persons who fall victim to alcohol's addictive qualities and whose health becomes seriously imperilled.

23. It was not part of Gilby Vollus Architects' brief to design and oversee the construction of the Detoxification Unit absent hanging points and its specification of a "break free" shower rail was not a response to a direction or request of the Department of Health & Human Services but rather was a choice governed by reason of architectural design.

24. That no criticism should be made of either the architect or the builder, Anderson Builders for not ensuring that the bathroom where Mrs Lyall died was fitted with a break free curtain rail. It would not be appropriate and is not available on the evidence to make any finding that any conduct on the part of Gilby Vollus Architects, Anderson Builders or any of their principals or employees contributed to Mrs Lyall's death.

25. It is my recommendation that the Department of Health & Human Services ensure that the Detoxification Unit be free of all obvious and likely hanging points. However, I need to make it clear that by this recommendation it is not intended to advise that there be a total ban on all hanging points, both real and potential, as would, for example, be necessary in a jail accommodating indigenous Australians or a high dependency unit housing at risk psychiatric patients.

26. I further recommend that the Department ensure that it require its architects to give consideration to environmental risk factors including hangings points when required to design and oversee the construction of any facility likely to be occupied by persons suffering from alcohol and/or drug addiction.

INTRODUCTION

Mrs Jakyung Seo Lyall ("Mrs Lyall") was born in South Korea on 28 October 1974. Since 2000 she had resided in Launceston with her husband Kevin James Lyall.

Mrs Lyall had a long history of alcohol abuse and had, since September 2006, been periodically detained in a Detoxification Unit located in the Carruthers Building at St Johns Park in New Town ("the Unit"). At about 7.30 pm on 19 October 2006 she was found hanging from a shower curtain rail in a bathroom of the Unit. Attempts to resuscitate Mrs Lyall by Unit staff were unsuccessful and life was declared extinct by Dr K. Blackman of the Royal Hobart Hospital ("the RHH").

State Forensic Pathologist, Dr Christopher Lawrence, conducted a post-mortem examination of Mrs Lyall. He reported the cause of death to be "hanging during treatment for alcohol and benzodiazepine withdrawal."

This inquest has in large part focussed upon the Unit and its staff and whether any aspect of the management, care and treatment of Mrs Lyall whilst a patient of the Unit has contributed to her death and/or requires the making of any coronial recommendation and/or comment.

THE UNIT AND ITS STAFFING

The Unit is a facility of the State of Tasmania's Alcohol and Drug Service which was a division of the Department of Health and Human Services ("the Department"). It previously was located at 56 Collins Street in Hobart but was re-located to St John's Park in mid-2006. It began receiving inpatients in July. The Unit has a 10 bed capacity but its occupancy rate averages about 50%.

At the time relevant to this inquest Dr Cindy Clayton was the Unit's Medical Officer. She is a qualified medical practitioner and since 1996 had specialised in the treatment of patients with alcohol and drug dependency. However, she was not a Fellow of the Addiction Medicine Chapter of the Australian College of Physicians. Prior to Mrs Lyall's death Dr Clayton had treated four other patients of the Unit on treatment orders for alcohol dependency. Initially, Dr Clayton directly reported to Dr David Jackson who was the Clinical Director of the Alcohol and Drugs Service. He resigned in February 2006. From March to June 2006 Dr Clayton acted in the position of Clinical Director until the appointment of Dr John Crawshaw. The current Clinical Director of the Service is Dr Adrian Reynolds who commenced in that position in February 2007.

The Alcohol and Drug Service also operated a Pharmacotherapy Unit which was responsible for administering a methadone programme involving about 100 patients. It had previously operated from 56 Collins but it too, in mid-2006 was re-located to St John's Park. It physically adjoins the Unit.

The evidence shows that at and around the time of the re-location of the Unit and the Pharmacotherapy Unit to St John's Park the Alcohol and Drug Service experienced significant staffing changes. In May 2006 Ms Gwen Von Gehr, the Clinical Nurse Consultant who managed the methadone programme, resigned. At about the same time an experienced methadone nurse also resigned. In August 2006 Ms Marianne Hagge was appointed to Ms Von Gehr's position but the duties attaching to the position were expanded so that her responsibilities included management of the nursing staff in both the Pharmacotherapy and the Detoxification Units. After Dr Jackson's resignation in February 2006 the Services' medical duties were shared by Dr Sue Sheehan and Dr Clayton. However, Dr Sheehan also resigned in May 2006 and thereafter Dr Clayton was the sole medical practitioner responsible for the patients of both the Unit and the Pharmacotherapy Unit. This situation persisted up to and including the periods of Mrs Lyall's admissions.

Ordinarily the Unit was manned by two nursing staff and a Detoxification Officer and this was the case at the time of Mrs Lyall's death. At this time the Unit was accommodating three patients including Mrs Lyall.

The Unit did not have on its staff a psychiatrist or psychologist. Nor did it have any in-house counselling service. This was consistent with its underlying ethos that detoxification was the focus of its treatment. Also consistent with this ethos was the absence of any established linkages to counselling, rehabilitation and outpatient services which could be utilised by a patient upon discharge.

An observation upon Dr Clayton:

During the course of the inquest evidence was received which raised as an issue whether some personal health difficulties had adversely impacted upon Dr Clayton's capacity to properly perform her duties as a medical practitioner in the unit and in particular in her care of Mrs Lyall. I am satisfied, having heard and considered all the evidence touching upon these matters, that Dr Clayton's capacity to work as a medical practitioner in the Unit and to be responsible for Mrs Lyall's care was not affected by her personal health problems. This finding makes it unnecessary for me to consider this subject further.

THE UNIT AND THE RELEVANT LEGISLATION

The Alcohol and Drug Dependency Act 1968 ("the Act"), as its preamble states, makes provision for the treatment and control of persons suffering from alcohol or drug dependency. By s3 a person shall be regarded as suffering from alcohol dependency if either he consumes alcohol to excess and is thereby dangerous at times to himself or others or he is incapable at times of managing himself or his affairs or shows prodromal signs of becoming so dangerous or so incapable.

Division II of Part II of the Act allows for the establishment of treatment centres for the detention of persons suffering alcohol or drug dependency. S15(1) provides that the Governor may declare any premises or part of any premises to be a treatment centre for the purposes of the Act. Ss15(2) and (2A) make provision for the appointment of a medical practitioner to be a Superintendent of a treatment centre and s15(3) obligates the Secretary of the Department to publish in the Gazette notice of that appointment. A patient may be admitted to a treatment centre upon an admission application made by himself or by a relative or a welfare officer (ss23(1) and (2)). Except in cases of personal applications, all admission applications are to be founded on the recommendation of a medical practitioner which incorporates an opinion that the patient is suffering from alcohol or drug dependency to a degree that warrants his detention in a treatment centre and that it is necessary in the interests of his health or safety and for the protection of others that he be so detained. (ss24(2), (3), (4) & (5)). An admission application is sufficient authority for the Superintendent of the treatment centre to cause the patient to be detained in the centre in accordance with the Act. s26(2).

By ss27(1) and (2) a patient admitted to a treatment centre may be detained in that centre for a period of six months which may be extended for a further period of six months upon provision of a report from a responsible medical officer opining that it is necessary that he be detained in the interests of the patient's health and safety or for the protection of others. S45(1) allows a responsible medical officer to grant a patient leave to be absent from the centre subject to such conditions (if any) as he considers necessary in the interests of the patient or for the protection of others. Any leave of absence may be revoked and the patient recalled to the centre if the responsible medical officer considers such revocation to be in the interests of the patient's health or safety or for the protection of others. (s45(4)). A person who absents himself from the centre without leave may be taken into custody and returned to the treatment centre by a centre staff member, police officer or any other person authorised in writing by the Superintendent of the centre.

Finally, it is noted that s61(1) provides that a person required or authorised under the Act to be detained in a place of safety shall be deemed to be in legal custody. "A place of safety," by s2(1) of the Act, includes a treatment centre.

I have set out the foregoing provisions in the Act because they have relevance to several issues which arise from the circumstances of Mrs Lyall's detention. I will deal with each of these in turn.

1. The Status of the Unit

The evidence shows that up to about mid-2006 persons requiring admission to a detoxification centre were received at 56 Collins Street in Hobart. That facility had been declared a treatment centre as required by s15(1) of the Act by the Alcohol and Drug Dependency (Treatment Centre) Amendment Order 1994 effective from 20 April 1994. As stated earlier the evidence also shows that the Unit began receiving patients from about July 2006. However, it was not until 28 February 2007 when the Alcohol and Drug Dependency (Treatment Centres) Order 2007 was notified in the Gazette that the Unit was declared a treatment centre for the purposes of the Act. It follows that in September and October 2006, being the periods relevant to this Inquest, the Unit had not been declared a treatment centre as required by the Act and hence did not qualify as a place where any person, including Mrs Lyall, could be lawfully detained against their will under the provisions of the Act. Any representation made to Mrs Lyall that she was obligated to remain in the Unit, that she was required to comply with any conditions attaching to a leave of absence, and that she could be recalled to the treatment centre upon revocation of any leave were all illegitimate and without legal foundation.

2. The Status of Dr Clayton under the Act

In March 2004 Dr Clayton commenced her employment with the Alcohol and Drug Service and by April of that year she was carrying out the duties of a medical officer at the Detoxification Unit (then located at 56 Collins Street). It was the evidence of Dr Clayton that in May 2005 she assumed the role of Medical Superintendent for the purposes of the Act. However, no direct evidence could be produced demonstrating her formal appointment to this position. More particularly, no evidence was forthcoming to establish that Dr Clayton or any other person had been specifically appointed as Superintendent of the Unit during the periods of Mrs Lyall's detention as required by s15(2) or s15(2A) of the Act. This leads me to formally find that no person had been appointed as required by the Act as Superintendent of the Unit for the period relevant to this Inquest and it therefore follows that neither Dr Clayton nor any other medical practitioner was empowered at that time to exercise those powers under the Act vested in the Superintendent. This included the power to detain Mrs Lyall in the Unit.

3. Was Mrs Lyall a person "Held in Custody?"

S28(5) of the Coroner's Act 1995 obligates the Coroner to report upon the care, supervision or treatment of a person who dies whilst held in custody or held in care. By s3 of the same Act, a person held in care includes "a person detained or liable to be detained in an approved hospital within the meaning of the Mental Health Act 1996 or in a secure mental health unit or another place while in the custody of the controlling authority of a secure mental health unit, within the meaning of that Act." The same section defines a person held in custody as:

(a) a person in the custody or control of -

(i) a police officer; or(ii) a correctional officer; or(iii) an authorised officer; or(iv) the controlling authority of a secure mental health unit; or(v) a prescribed person within the meaning of section 31 of the Criminal Justice (Mental Impairment) Act 1999; or(vi) a person who has custody under the order of a court for the purposes of taking the person to or from a court; or

(b) a person detained -

(i) in a prison as defined in the Corrections Act 1997; or(ii) in a building or part of a building at a police station used for the confinement of persons under arrest or otherwise lawfully detained in custody; or(iii) in a detention centre;"

At the time of her death Mrs Lyall was resident in the Unit. That facility is neither an approved hospital nor a secure mental health unit within the meaning of the Mental Health Act 1996. It follows that Mrs Lyall did not qualify as a person held in care as defined by the Coroner's Act 1995. It is my further opinion that she does not qualify as a person held in custody as that term is defined because she was not, upon the evidence, either a person in the custody or control of any of those person listed in sub para (a) of the definition nor was she a person detained in any of those facilities listed in sub para (b). It follows in my view that this is not an instance where I am mandated to report upon Mrs Lyall's care, supervision or treatment under s28(5). I reach this view notwithstanding s61 of the Act (see above) which stipulates a person detained in a place of safety to be deemed to be in legal custody.

Comment on the Legal Validity of Mrs Lyall's Detention

The Act clearly sets out those requirements to be met before a person can be validly detained in a treatment centre against their will. For the reasons stated I am satisfied that those requirements were not met in this instance and Mrs Lyall's detention at the Unit was hence invalid. It is evident that this situation arose from administrative oversight and was unintended. Nevertheless, this state of affairs reflects poorly on the competence of those persons who had the responsibility for administering the Act and ensuring compliance with the law.

BACKGROUND TO MRS LYALL'S ADMISSIONS TO THE UNIT

The evidence shows that Mrs Lyall had a long and extensive medical history associated with her abuse of alcohol. Principal elements of that history follow:

• Mrs Lyall was a patient of the Northern Suburbs Medical Service. It was the evidence of Dr Cas Stewart of that practice that in 2003 Mrs Lyall's use of alcohol was identified as a problem. In July 2003 liver function test results were stated to be "woeful." Mrs Lyall was referred to a counsellor attached to the Alcohol and Drug Service and in December 2003 there was some contact between Mrs Lyall and that Service.
• From March 2004 to September 2006 Mrs Lyall was admitted to St Vincent's Hospital on 14 occasions for management of her alcoholism and related medical conditions. At varying times she was admitted under the care of Gastroenterologist, Dr Middleton or Psychiatrists, Dr Ian Martin and Dr Surinder Johl.
• On 23 December 2005 Mrs Lyall was discharged from St Vincent's Hospital after a 37 day admission. Dr Middleton had arranged for her to be admitted to St Helen's Hospital in Hobart on 2 January 2006 to participate in a drug and alcohol rehabilitation programme but by this time she had resumed drinking and did not attend.
• In mid-January 2006 Mrs Lyall was admitted to St Helens Hospital on referral by Dr Middleton. By this time it was necessary for her to again undergo alcohol withdrawal. The documentation refers to "depression" as an allied reason for admission. Her care was managed by Psychiatrist, Dr Sheehan who made this comment; "this (lady has) marked cultural/social difficulties, isolation. Self-medicates to alcohol to reduce distress of loneliness. Little or no purpose in life outside the home." He assessed her risk of suicide as "low." The nurses' notes indicate that a drug and alcohol rehabilitation programme was offered to Mrs Lyall but she was reluctant to participate. The Hospital records also show that Mrs Lyall was discharged "home" after three weeks and that no follow-up arrangements were provided for.
• From 13 June to 7 July 2006 Mrs Lyall was an in-patient of The Hobart Clinic. She had been referred by Dr Middleton following a two week period of alcohol withdrawal whilst a patient in St Vincent's Hospital. The intended focus of the admission, as explained by Dr Stuart Hooper, the Clinic's Clinical Director was "relapse prevention skills training" along with encouraging Mrs Lyall "to set a goal of abstinence from alcohol as opposed to attempting to control her drinking." At assessment Mrs Lyall reported depressed moods since leaving South Korea six years previously. In his report Dr Hooper comments; "In my view her depressive symptoms were most likely to be secondary to her loneliness and social isolation particularly since relocating from South Korea to Australia, in addition to her alcohol dependence problem. Alcohol abuse and dependence not uncommonly can lead to depressive symptoms or disorders and vice versa. In terms of severity I don't think she had a severe form of depression given that she reported on some days she didn't feel depressed." At discharge Mrs Lyall was referred back to her general practitioner in accord with the Clinic's usual practice for patients from the north of the State. This contrasts with the Clinic's usual practice for Southern resident patients for whom the usual practice was "to offer day program follow up in which they can attend The Hobart Clinic day program on a weekly or twice weekly basis to reinforce the changes that they have made during their admission."
• It was Mr Lyall's evidence that approximately one week after her discharge from The Hobart Clinic his wife resumed drinking and this eventually led to her final admission to St Vincent's Hospital on 12 August 2006 where she remained to 7 September 2006. The hospital records suggest that during this period an enquiry was made of the Migrant Resource Centre to obtain some support for Mrs Lyall but the Centre has no record of any involvement with her.

Her medical history shows that Mrs Lyall had a severe and chronic dependence upon alcohol, that she appeared unmotivated or unable to embrace treatment and that she presented a very serious medical challenge if her life was to be saved from the inevitable consequences of her addiction.

MRS LYALL'S ADMISSIONS TO THE UNIT

12 September to 29 September 2006

Mrs Lyall resumed drinking almost immediately after her hospital discharge on 7 September 2006. Mr Lyall says that by this time he was "at his wit's end." He sought the help of Dr Mark Mackinnon of the Northern Suburbs Medical Practice. Dr Mackinnon spoke to Dr Clayton by 'phone and informed her that Mrs Lyall needed urgent treatment for her alcohol related problems including cirrhosis and a possible head injury. He requested that she be an involuntary admission to the Unit. In his view Mrs Lyall was in need of urgent treatment to save her life. It was Dr Clayton's evidence that she advised Dr Mackinnon of the limited benefit of an involuntary admission and that it would be preferable that she either admit herself voluntarily or that she utilise outpatient services. Nevertheless, the process for involuntary admission was initiated by Dr Mackinnon and the following morning Mrs Lyall was received at the Unit having been transported via the Launceston General Hospital ("the LGH") and then the RHH where she had a medical assessment. At 10.00 am she was the subject of a "screening" carried out by staff at the Unit. The Screening Report recorded the reason for Mrs Lyall's presentation to be "husband and GP have put patient on an ADDA order due to her alcoholism - consumes 3L+ of cask wine per day." The report further notes "Current Issues"; "? Depression. ? Anorexia - emaciated weighs 41kg." The document also records; "Separated from husband for 1 week."

In the afternoon of that day Mrs Lyall was seen by Dr Clayton. The clinical notes record under "Diagnosis" these comments, "Alcohol dependence. Cirrhosis. Depression - has not had treatment. Risk of dehydration. Not happy with situation." It was Dr Clayton's evidence that this assessment amounted to a psychiatric evaluation of Mrs Lyall and, in her view, it did not cause her to believe that Mrs Lyall should be referred for a full psychiatric assessment. However, Dr Clayton in her affidavit makes this statement; "It is usual to arrange for neuropsychiatric evaluation for alcoholic patients with poor health and this would have been part of her follow up." She added; "Patients have to be sober for 6 weeks before the results of such an assessment are valid."

The treatment plan noted by Dr Clayton at that time included alcohol withdrawal and the encouragement of fluid and food intake. She was prescribed the antidepressant Lexapro. Too, she was prescribed diazepam for withdrawal, temazepam for night time sedation and acamprosate for longer term maintenance of abstinence.

At some time Dr Clayton had a 'phone conversation with Mr Lyall. He informed her that there had been many previous hospital admissions including the recent three week admission to St Vincent's Hospital. He outlined some of the stressors in her life and asked if she could be admitted to the Hobart Clinic.

The clinical notes shows that Dr Clayton next saw Mrs Lyall on 19 September and the management plan made at that time included "Refer counsellor in Launceston." That same day Enrolled Nurse, Ms Anne-Maree Coppleman has recorded, "Keith Ellis ADS North has details and will be able to organise support when Jakyung returns home." Another entry made by Ms Coppleman on 21 September records; "ADS North contact to organise support for Jakyung post discharge."

Towards the end of her admission Dr Clayton described Mrs Lyall as appearing to be "happy and healthy, and was a delight to have around."

Mrs Lyall was discharged from the Unit at 6.45pm on 29 September when she was collected by her husband. The discharge notes record that a follow up appointment had been made for Mrs Lyall to attend a counsellor with ADS North on 2 October at 2.00 pm.

A "Discharge Formulation" form completed by Dr Clayton at this time describes Mrs Lyall's management during the period of this admission in these terms;

"Admitted under ADD Order for alcohol and benzodiazepine detox. Diazepam loaded. Diazepam tapered over duration of mission. Progressed well though remained isolative. Complained of ongoing joint pain, especially (R) side and given Mobic with effect. Lactulose ceased and replaced with bulking laxative, since treatment is for haemorrhoids. Campral started. Started on Lexapro for depression. Arrangements made for follow up in Launceston with regard to counselling. Psychologist Peg LeVine at UTas Launceston, specialist in migrant issues contacted for assistance and reply pending. Continued on 6 month ADDA Order with Leave Pass given and conditions explained to Jakyung."

Under the heading "Follow Up" this was noted;

"GP, Dr Middleton for medication and follow up of liver disease.

Adds North for counselling."

Copies of this form were dispatched to Dr Mackinnon and to Dr Middleton.

During this admission Dr Clayton sought information upon Mrs Lyall's admissions to the LGH, the Hobart Clinic and St Vincents Hospital. Nothing had been received from the latter at the time of discharge. However, the Unit had received, by fax, Mrs Lyall's Discharge Summary from the Hobart Clinic along with some limited material including discharge documents from the LGH.

3 October to 15 October 2006

Mrs Lyall promptly resumed drinking after she returned to her Launceston home. This led to her husband again taking her to the LGH where arrangements were made for her return by ambulance to the Unit. She arrived at 4.00pm on 3 October. The clinical notes made at that time record; "She was in a very sedated state and had to be assisted to bed. Admission procedures could not be completed because of client's state."

Dr Clayton saw Mrs Lyall on 4 October noting that her observations were stable and that she was sleeping well. She further noted that she was "not happy to be here." The plan then was to discuss her situation further "when (her) anger subsides." There is a note made on 4 October that nursing staff spoke to Mr Lyall by 'phone and discussed with him the future options for his wife. It was suggested that Mrs Lyall remain in the Unit for two weeks and for her then to be discharged to her husband "if he was willing to give it another go."

On 5 October a parcel of clothing arrived for Mrs Lyall. A razorblade was found wrapped in foil within the parcel. It was removed by nursing staff. Dr Clayton spoke to Mrs Lyall about this. She explained that she used it to shave her face and seemed shocked at the suggestion that she may use it to harm herself. In Dr Clayton's view Mrs Lyall at this time did not demonstrate any behavioural factors indicative of significant depression and she was satisfied that she was not intent on self-harm. On the same day Mrs Lyall requested that she be moved to a single room and that she be given access to a computer. Dr Clayton agreed that she could have her computer twice daily for one hour sessions. She would not approve a room change and encouraged Mrs Lyall to interact with staff and other patients. Mrs Lyall was informed that she would be kept in the Unit for two weeks.

Mr Lyall telephoned the Unit on 11 October following a 'phone conversation with his wife when she informed him that she would resume drinking upon discharge. This upset Mr Lyall and he "wanted to know what can be done for her." Nursing staff explained to him that the Unit provided withdrawal assistance only and it did not offer an in-patient counselling service.

On 15 October Mrs Lyall was discharged from the Unit. She was collected by her husband at 11.30am. As previously, she signed a Leave of Absence form which was issued on the sole condition, "you must not drink alcohol." There is not any record of any follow up arrangements having been put in place for Mrs Lyall to receive out-patient counselling or other assistance. However, it was Dr Clayton's evidence that she tried to encourage Mrs Lyall to undertake voluntary treatment either through Dr Mackinnon or a counselling service. Dr Clayton was aware at this time that Mrs Lyall had failed to attend the appointment made for her with ADS North after her previous discharge.

17 October to 19 October 2006

Again Mrs Lyall resumed drinking alcohol almost immediately after returning to Launceston. On 17 October Mr Lyall again took his wife to the LGH and arrangements were put in place for her transportation back to the Unit. She had been aggressive when presenting at the LGH and was reluctant to be re-admitted to the Unit. She was sedated so that when she arrived at the Unit she was unable to remain awake and had to be assisted from the vehicle with the aid of a wheelchair. That evening she was examined by Dr Clayton who directed that she be subjected to half hourly observations for two hours and then hourly.

On that same day Dr Clayton sent an email to her acting regional manager prompted by an apparent complaint made by Mr Lyall about his wife's care in the Unit. In that email Dr Clayton says; "Mrs Lyell (sic) has had comprehensive management. The next step is to organise a case conference of all those involved in her care - herself, her husband, the GP, her counsellors from ADS North, a representative of LGH, us, and perhaps even Police as they have had some involvement. The case conference would aim to achieve a greater understanding of Mrs Lyell's (sic) problem by all those involved in her care, particularly the nature of her problem, and to achieve an on-going management plan agreeable to all." This initiative had not been acted upon before Mrs Lyall's death.

Also on 17 October Dr Clayton emailed Dr Crawshaw and sought his advice upon Mrs Lyall's management. Dr Crawshaw had not replied by the time of Mrs Lyall's death.

Dr Clayton was absent from the Unit on 18 and 19 October, she having taken pre-arranged leave to attend an interstate conference. It was presumed by Dr Clayton that management would arrange for Dr Chris Wake to be on call to attend to any emergencies in the Unit during her absence.

Enrolled Nurse Linda Ingram was on duty at the Unit for the day shift on 18 October. She described Mrs Lyall's mood at that time as being "very low" and that she had stated that she "just wants to go home (to Launceston)." Ms Ingram was aware that during that day Mrs Lyall had asked nursing staff that she be able to speak to Dr Clayton but she was not seen by Dr Clayton on that day. On the afternoon shift of 18 October Ms Coppleman was caring for Mrs Lyall. In the notes made during her shift Ms Coppleman records that Mrs Lyall "expressed great dissatisfaction at being here and is very angry with her husband for calling the ambulance in Launceston. Jaki would like to speak to M.O and have the ADDA explained - states all she does is eat/sleep and get pills. I asked her if she wanted to go to Hobart Clinic but she did not know. Jaki states she would like to go to Korea to see her parents but some ? flaw ? in passport."

Ms Ingram also worked the day shift on 19 October. She described Mrs Lyall's mood that day as "really sad and low…..probably more so than in the past." It was her further evidence that Mrs Lyall had told her that she wanted to talk to her but that she had been busy the entire shift and there had not been an opportunity to sit down with her. Ms Coppleman was again on duty on the afternoon shift of 19 October commencing at 3.00 pm. She described Mrs Lyall at that time as "sad." At one time during the afternoon Mrs Lyall asked for permission to telephone her husband. She tried to call him but could not make contact. Ms Coppleman says that sometime between about 5.30 and 5.40 pm she observed Mrs Lyall in the courtyard having a cigarette. She was in the presence of two other patients.

At about 7.10 pm Ms Coppleman went to the staff room for her evening meal. She was there about 20 minutes. When she left she walked along the hallway and heard water running in the bathroom. She knew that it must have been Mrs Lyall in the bathroom because she had just seen the other two patients who were still in the courtyard. She called out Mrs Lyall's name and there was no response. She said that there is a gap under the bathroom door and she looked through it but could not see anything. She then pushed the door open and entered the bathroom. She observed water overflowing from the bath and could see Mrs Lyall hanging within the shower cubicle. Ms Coppleman yelled for help. Detox Officer Gary Vince and Registered Nurse Hannah Troy were in the nearby Nurses' Station. They immediately went to the bathroom. They observed Mrs Lyall hanging within the shower cubicle from an electrical computer cord. Mr Vince took her weight whilst Ms Troy cut the cord using scissors. Mr Vince began CPR but was unable to revive her. Ambulance personnel arrived and then transported Mrs Lyall to the RHH where life was declared extinct.

EVIDENCE OF PROFESSOR JON CURRIE

Professor Jon Currie is a highly qualified practitioner in the speciality of addiction medicine with widespread experience in the field. Since 2006 he has been the Director of Addiction Medicine at St Vincent's Hospital in Melbourne. For 12 years prior to this he was the Director of Drug and Alcohol Services for the Western Sydney Area Health Service. Professor Currie provided a comprehensive proof of evidence to assist the inquest. He also attended in person and was cross-examined. It is convenient that I set out the salient points of his evidence. They follow:

• There is an increased risk of suicide for those patients who are both alcohol dependent and depressed and in these cases it is necessary to treat both conditions.
• For a small number of patients there is a role for the compulsory treatment of alcohol dependency in a detoxification unit.
• The essence of effective compulsory treatment is that there must be effective medical treatment rather than simply detaining the person to exclude them from using alcohol or drugs. The essence of that treatment is a comprehensive and thorough treatment plan. Mere detention of a patient does not constitute adequate treatment.
• A detoxification unit should avail a patient of these services:

a) Pharmacological care to treat withdrawal, craving and risk of relapsing.
b) Psychological support by counselling.
c) Psychological assessment with a capacity to identify and treat symptoms of psychiatric illness whether addictive behaviour or other psychiatric illness such as depression. Where symptoms of psychiatric illness are severe a capacity for referral to specialist psychiatric services.
d) Regular assessment and monitoring by a medical officer experienced in addiction medicine.
e) An overall comprehensive treatment plan.
f) A discharge plan addressing long term goals, treatment and management of the patient.

• Given the high incidence of patients who are depressed a detoxification unit should be inspected and assessed for inherent risks of self-harm or suicide. A detoxification unit should not have any hanging points.
• The risk of relapse to drinking in alcohol dependent persons who do not receive follow up treatment after discharge from detoxification may be as high as 90%, even in the short term.
• That the aim of Professor Currie's facility at St Vincent's Hospital in Melbourne is to achieve between 60 to 70% abstinence from alcohol at 5 years post detoxification and that for the last two years the achieved rate has been 62%.

Professor Currie made these observations specific to Mrs Lyall and her treatment and management by the Unit:

• Mrs Lyall's history indicated a severe level of alcohol dependence and her case would represent one at the most complex and difficult end of the management spectrum.
• Mrs Lyall's management was particularly sub-optimal in that a comprehensive treatment and management plan was not devised for her in either the short or long term.
• The principal aim of the Unit appeared to have been to recurrently gain the passage of time without exposure to alcohol. This did not constitute an adequate treatment for her severe level of alcohol dependence.
• In a situation where an in-patient at the Unit on a compulsory basis had rapidly failed twice to produce any behavioural change it ought to have been apparent to Dr Clayton and to the staff of the Unit that whatever treatment plan was being applied during the previous admissions was not effective and that further episodes of similar involuntary detention without a change in treatment plan were likely to be both similarly unsuccessful and to cause increasing distress to the patient.
• The recurrent admission, discharge and re-admission cycle without substantive management planning, monitoring and re-planning in response to clinical relapse and treatment failure did not represent best clinical practice within Australia in 2006.
• A patient given leave of absence while still subject to a detention order requires very close clinical supervision, monitoring and treatment. It is inadequate, as was the case with Mrs Lyall, to rely on a condition that she "not drink" as a method of treatment. Such a condition is very unlikely to succeed and sets up the patient for failure and the trauma of involuntary re-admission. If the patient relapses which is very likely because of the nature of the illness and is then "re-incarcerated" he/she is very likely to experience escalating levels of anxiety and depression. (Dr Clayton, in her evidence, acknowledged the "do not drink" condition as non-sensical).
• Mrs Lyall appears to have had at least two psychiatric diagnoses of depression and an eating disorder made at various times in addition to her alcohol addiction. In any setting of in-patient detoxification, but particularly in the setting of involuntary detention, the existence of these diagnoses mandates the need for psychiatric assessment to form part of a comprehensive assessment and management plan upon admission to the detoxification facility and for subsequent psychiatric review to be considered upon subsequent admissions. Mrs Lyall's should have undergone a psychiatric review at some time during her admission.
• Neither St Helens Hospital nor the Hobart Clinic nor the Unit at the end of Mrs Lyall's first two admissions seems to have adopted a comprehensive ongoing treatment plan to apply at the time of discharge.
• It is imperative for the optimal management of severe alcohol dependence that a patient, upon discharge or leave of absence from a detoxification unit, has in place an intensive out-patient treatment plan. A plan of management for such a chronic and complex case as presented by Mrs Lyall may include extensive use of pharmacotherapy and even, initially, daily nurse visits to ensure compliance with the medications used. Also, the provision for frequent counselling sessions and other lifestyle psycho-social support services co-ordinated through a single case manager or case management system would be essential. The plan would also need to include the treatment of her co-morbid psychiatric disorders.
• It is inadequate just to advise patients who are alcohol or drug dependent that they should simply seek further treatment on their own after discharge or when granted leave of absence. It is an essential role of the treating doctor in a detoxification unit to design and co-ordinate the initial implementation of a comprehensive post-discharge management plan before the patient is discharged or granted leave of absence. Such discharge planning should actually commence at the initial time of admission to the detoxification unit, be modified by the progress of the patient during admission and be agreed and established before the patient is discharged. In Mrs Lyall's case the strategy of holding her in the Unit to keep her away from alcohol and then discharge her without a comprehensive follow up plan of management was not an acceptable treatment plan.
• It is essential that a detoxification unit perform a risk assessment for depression and self-harm/suicide each time a patient is admitted to its facility and this is particularly important in the case of patients undergoing involuntary detention. It is also important that risk assessment tools be administered not just at the time of admission but regularly across the period of an in-patient admission to evaluate changes in the mood status, particularly if increased levels of risk are identified at admission.

• The chronicity, complexity and severity of Mrs Lyall's history warranted, at a minimum, a case conference review to have been convened between the various health and welfare professionals involved in her care and a comprehensive and properly case managed short, medium and long term treatment program to have been devised and appropriate clinical responsibilities and recourses to have been agreed and allocated. Without such management plan being in place Mrs Lyall's treatment was scattered, un-co-ordinated and inadequate. Dr Clayton's email dated 17 October 2006 advising of the intention to put in place a case conference was a proper step but one that should have been taken in the early part of Mrs Lyall's first admission to the Unit.

• At the time of Mrs Lyall's third admission on 17 October it was recorded by Dr Clayton that she was heavily sedated and no proper assessment of her medical condition or her psychiatric state was capable of being undertaken at that time. Subsequent to this Dr Clayton was absent from the Unit on leave for the period up to Mrs Lyall's death and accordingly no medical or psychiatric assessment was undertaken upon her. This represented inadequate care.

• Mrs Lyall's case was not "routine" and may have warranted thinking "outside the square." This could have included referring her to a facility interstate, seeking the advice/assistance of interstate practitioners and/or the introduction pharmacological regimes commonly used in the United States and Europe but less so in Australia.

• Professor Currie rejected the notion that the treatment regime which he believed should have been provided to Mrs Lyall was "gold star." In response to that suggestion he stated; "…..the answer is no, it's not gold star, it is in fact - it is average. Gold star is far more than that. Gold star would have bells and whistles well beyond that. ……If you're going to deprive (a) patient of their liberty, you must provide the best possible treatment. You cannot do less. And the point is that this patient, in fact, deserved at least a discharge plan." Professor Currie described the care actually provided to Mrs Lyall as being "B grade treatment." He said, speaking of her treatment history; "To do the same thing over and over again and expect a different result is madness, it's not going to happen, so you've got to keep changing what you do."

In my view Professor Currie was a most credible witness whose evidence was particularly illuminating and helpful. I accept it. In doing so I specifically reject the notion that the level of treatment advised by Professor Currie was "gold standard" and was not in accord with the standard of treatment available in other jurisdictions in Australia in 2006.

Professor Currie's evidence, in large measure, is the basis for my specific findings and comments upon Mrs Lyall's care and treatment as a patient of the Unit. They follow.

FINDINGS AND COMMENTS UPON MRS LYALL'S TREATMENT AND CARE

The evidence shows, and I find, that the only service the Unit was able to offer an involuntary alcoholic patient was detoxification involving denial of alcohol and management of the withdrawal process with drugs and nursing support and little more. Such a service was, in my opinion, grossly inadequate and was unlikely to provide any real and lasting benefit for chronic alcohol addicted patients. Particular shortcomings in the level of care and treatment provided by the Unit included:

• The absence of an in-house counselling service;
• The incapacity to enable patients to have ready access to a psychiatrist for assessment and, if necessary, for admission to a psychiatric facility. In this respect it is relevant to observe that Dr Clayton did not have any patient admission rights to the Royal Hobart Hospital;
• The failure to have in place any linkage or professional association with any counselling, rehabilitation or other outpatient resource able to provide on-going assistance to patients as an outpatient service.
• The absence of a patient management system which mandated the timely establishment of a comprehensive treatment plan (which would necessarily require, at an early stage, a case conference involving all interested parties) together with discharge plan which detailed the patient's future treatment and long-term management.

The foregoing matters lead me to conclude that the Unit did not have the capacity to provide patients suffering from intractable alcoholism such as Mrs Lyall with a standard of treatment which their condition required and which they and their families were entitled to expect. Professor Currie has described the level of care available to Mrs Lyall as being "B grade." Dr Clayton's counsel accepts this as an accurate description. I agree.

On the day of her first admission to the Unit Mrs Lyall underwent a "screening" carried out by staff and was examined by Dr Clayton. On this day Dr Clayton also spoke to Mr Lyall. Previously she had spoken to Dr Mackinnon. The information received from these sources should, from the outset, have alerted Dr Clayton to the fact that Mrs Lyall was not a "routine" patient who was likely to be "cured" by the detoxification treatment which the Unit was able to offer and that her circumstances required a more considered and comprehensive approach. The treatment plan which in fact was embarked upon, and was confined to detoxification followed by a discharge which was largely unplanned and un-monitored and conditional on abstinence, was in my view grossly inadequate and unlikely to be of any benefit. To settle on this course of treatment was an error compounded by its repetition when Mrs Lyall was re-admitted following the inevitable breach of the non-drinking condition.

In my view Mrs Lyall's care and treatment required, at the time of her first presentation, a management plan which, in the least, incorporated the following:

• A course of detoxification with pharmaceutical support;
• The securing of a full history of Mrs Lyall's illness. This included the need to obtain a full account of Mrs Lyall's previous treatments. This account would have revealed a record of multiple hospital admissions involving St Vincent's (in this case totalling 14), the LGH, and St Helens Hospital along with an admission to the Hobart Clinic, all occurring within the previous 2.5 years. The material would have clearly demonstrated the chronicity of Mrs Lyall's alcohol abuse and the nature of her associated illnesses including formal diagnoses of depression, liver damage and an eating disorder. Too, it would have illustrated Mrs Lyall's reluctance to embrace out-patient therapies and reinforced the pointlessness of a treatment principally focussed on drug-assisted detoxification;
• The convening of a case conference. Such conference needed to involve all interested parties which would, at the outset, have included Mrs Lyall, her husband, Dr Clayton, Dr Crawshaw, Dr Mackinnon and perhaps Dr Middleton. The first issue to be addressed was the capacity of the Unit to provide Mrs Lyall, in the light of her history, with a course of treatment that had some prospect of serving as a start-point to her rehabilitation. Absent that capacity the conference needed to, as Professor Currie has stated, "look outside the square" and possibly explore seeking treatment and/or assistance from interstate. This may have involved the need to explore the financial assistance available to Mrs Lyall by Medicare and her private health insurer. If it was determined that the Unit could provide a service likely to be beneficial to Mrs Lyall then there was a need at the conference to settle on a plan for the delivery of that service during the in-patient phase. More critically, the case conference needed also, in my view, to closely consider those options available for the outpatient management of Mrs Lyall. This may have involved exploration of the further involvement of the Hobart Clinic and/or St Helens Hospital and their outpatient counselling services, the access to psychiatric and counselling assistance in the Launceston area and the means of maximising Mrs Lyall's participation in an outpatient programme. The conference needed also to address the terms of any conditions which should attach to a Leave of Absence and which may assist in Mrs Lyall's out-patient management.
• A resolve for Mrs Lyall not to be discharged until a firm plan was in place for Mrs Lyall's care and treatment post-detoxification.

After Mrs Lyall was discharged from the Unit on the first occasion she almost immediately resumed drinking alcohol. She was promptly re-admitted. These circumstances should have made doubly evident to Dr Clayton the inadequacy of the plan settled upon for her care and treatment during the first admission and the urgent need for a different approach. Regrettably, this did not occur and Mrs Lyall's previous treatment regime was repeated. When discharged this time the Leave of Absence was upon the same condition, which Dr Clayton has since acknowledged was non-sensical. Dr Clayton's decision to repeat Mrs Lyall's previous treatment regime without variation was, in my view, a serious misjudgement on her part given that such regime had so spectacularly failed following the first admission. That failure should in the very least have demonstrated the need for a case conference to be convened and for a comprehensive management plan to be settled upon before discharge was permitted. It is pertinent to observe that upon Mrs Lyall's third admission Dr Clayton did, before taking two day's leave inform her manager of the intention to convene a case conference. She also emailed seeking the assistance of Dr Crawshaw. These steps, whilst appropriate were, grossly overdue.

It was the opinion of Professor Currie that repeated involuntary admissions to a detoxification facility are likely to be traumatic and cause escalating levels of anxiety and depression. I accept this opinion. It is logical. It is consistent with nursing staff describing Mrs Lyall as being "sad" at the time of her third admission. As I have noted earlier, Dr Clayton was absent from the Unit on pre-arranged leave for the two days prior to Mrs Lyall's death. It was her expectation that Dr Wake would attend at the Unit if a medical practitioner's services were required. However, it appears from the evidence that Dr Clayton did not specifically alert the Unit's nursing staff to the possibility that Mrs Lyall's re-admission may cause an increased level of anxiety and depression which may necessitate medical assessment. Although the nursing staff had, as I have said, noted Mrs Lyall to be "sad" they did not consider her condition to be sufficiently concerning to warrant Dr Wake being summoned. It seems with hindsight that this was a misjudgement. It is not possible for me to say whether a mental state examination undertaken by Dr Wake during this third admission would have identified an increased likelihood of self-harm requiring a greater level of vigilance by Unit staff or other preventative measures.

THE UNIT AND THE ISSUE OF CONTRIBUTION

S28(1)(f) of the Coroners Act 1995 obligates me to identify any person who contributed to the cause of Mrs Lyall's death. In the context of the Unit potential contributors are its nursing staff, Dr Clayton and/or the party responsible for its operation, namely the State's Alcohol and Drug Service as a division of the Department. I will deal with each in turn.

The Nursing Staff

Mrs Lyall died by her own hand. During the last 48 hours of her life she had been nursed by both Nurse Ingram and Ms Coppleman. They had variously described her mood over this period as "really sad and low……probably more so than in the past," "very low" and "sad." She had a known history of depression and it should have been evident to the Unit's experienced nursing staff that Mrs Lyall's history of repeated admissions was likely to have caused an escalation in her levels of anxiety and depression. As against this, Mrs Lyall's history did not include any threats or attempts at self-harm, signs of suicide ideation were absent and mental state examinations undertaken by Dr Clayton during earlier admissions had not indicated an increased risk of suicide. Notable among these was the assessment undertaken during the second admission when a razor blade was found among Mrs Lyall's belongings. Having regard to all these matters and bearing in mind the very real difficulty of predicting an act of self-harm it would, in my view, be inappropriate to make a finding that the nursing staff had contributed to Mrs Lyall's death by their failure to recognise the likelihood of her self-harming and putting in place, without a medical assessment and upon their own initiative, steps including increased levels of vigilance to frustrate that outcome.

Dr Clayton

Dr Clayton was, at the relevant time, a medical practitioner with 10 years' experience in the treatment of alcohol and drug addiction. She was also the acting Clinical Director of the Alcohol and Drug Service. On each occasion that Mrs Lyall was involuntarily admitted to the Unit Dr Clayton was the practitioner responsible for providing her with appropriate and proper care. I have sought above to set out deficiencies or shortcomings in that care. They can be summarised thus:

• The failure to obtain a full history of Mrs Lyall's illness during her first admission including relevant medical records;
• The failure to convene a case conference during Mrs Lyall's first admission to explore all treatment options available to Mrs Lyall both within and outside the Unit and to settle on plans for her in-patient and post-discharge care;
• Providing Mrs Lyall with a course of treatment confined to drug-assisted detoxification when she knew, or ought to have known, that it was unlikely to be of any real and lasting benefit to Mrs Lyall;
• The failure to put in place a comprehensive patient management plan during Mrs Lyall's first admission;
• Permitting Mrs Lyall's discharge following the first admission without having ensured that a proper plan was in place for Mrs Lyall's care and treatment post-detoxification;
• Failing to attach conditions to Mrs Lyall's Leave of Absence which were in accord with a proper discharge plan, were not non-sensical and were practical and more likely to be beneficial to her treatment;
• Replicating for her second admission the unsuccessful course of treatment and management provided to Mrs Lyall for her first admission;
• Failing at an earlier time to seek the assistance and/or guidance of Dr Crawshaw or other senior practitioner; and
• Failing to ensure that nursing staff were alert to the possible need for an assessment of Mrs Lyall's mental state at the time of her third admission and while Dr Clayton was absent interstate.

Has Dr Clayton contributed to Mrs Lyall's death by providing her with a level of care which, in my view, fell short of that standard of care which she was entitled to receive? This question must be considered by reference to her working environment, namely the Unit. As I have noted, it was ill-equipped and insufficiently resourced to provide alcohol-addicted patients with a course of treatment beyond detoxification. Furthermore, it did not have in place an established structure to ensure that its patients received a properly planned and managed treatment, both as an inpatient and after discharge. The deficiencies in the level of care provided by Dr Clayton were almost entirely a consequence of these systemic failings within the Unit. In these circumstances it would not, in my view, be appropriate to make a finding that Dr Clayton contributed to Mrs Lyall's death.

The Alcohol and Drug Service

I have attempted to set out above the inadequacies in the capacity of the Unit to provide Mrs Lyall with an appropriate standard of treatment and my criticisms of the actual treatment provided. Has the Unit, by its sub-standard care of Mrs Lyall, contributed to her death?

I am satisfied, and so find, that the revolving-door form of treatment provided to Mrs Lyall, in all probability, caused her an increased level of anxiety and depression. However, I am unable to find that this was the trigger, when considered in the light of her entire medical and social history, which caused her to take her own life. It follows that I cannot be satisfied that the Alcohol and Drug Service did by its care of Mrs Lyall in the Unit contribute to her death. Nevertheless, I am satisfied and do find that the Service did, by its provision of sub-standard care, deny Mrs Lyall that 60% or thereabouts chance of being successfully treated which Professor Currie's evidence has shown to be reasonably achievable.

THE SHOWER CURTAIN RAIL AND THE ISSUE OF CONTRIBUTION

In mid-2005 architectural firm, Gilby Vollus Architects was retained by the Department to design a facility within the Carruthers Building at Newton Town suitable to accommodate the Unit and to supervise its construction. Anderson Builders were appointed by the Department to carry out the building work. Its principal was Mr Geoffrey Anderson.

The plans and drawings prepared by Gilby Vollus Architects included a specification that the shower curtain rail to be installed in the bathroom where Mrs Lyall subsequently died was to have a "break free" fitting. It was the evidence of Mr Paul Gilby of Gilby Vogus Architects that "break free" bathroom fittings are available and it was his understanding that they are designed to give way under a load of 30 to 40 kgs. He explained that the "break free" feature was not in the rail itself but rather in its fixing.

Mr Anderson acknowledged that either he or an employee installed the curtain rail but they utilised a standard rail type regularly used in Australian hospitals. It was Mr Anderson's evidence that he did not have any knowledge of a shower curtain rail specifically designed to be "break free" and that he had not appreciated the significance of this description in the design specifications.

It was Mr Gilby's evidence that an inspection of the building works was undertaken by Gilby Vogus Architects upon their completion but that inspection did not identify that the curtain rail installed in the relevant bathroom was not "break free." He accepted that no direction was given to the builder to replace the rail with one which complied with the "break free" specification.

Mrs Lyall was able to successfully utilise the curtain rail as a hanging point because it remained fixed under her weight. She weighed 41.6kg at autopsy. These circumstances give rise to the question whether a finding can be properly made under s28(1)(f) of the Coroners Act 1995 that the architect and /or the builder contributed to Mrs Lyall's death by failing to ensure the installation of a "break free" curtain rail?

As I have observed, Mrs Lyall weighed just 41.6kg, a weight which only just exceeded the upper loading limit of the "break free" rail described by Mr Gilby. There is not any evidence specific to these rails, the fixing options (if any), the accuracy of the stated loading range, their "break away" mechanism and in particular upon the likelihood of that mechanism being triggered by Mrs Lyall's specific weight. The evidence, as it stands, does not, in my opinion, permit a positive finding that a "break free" rail of the type described by Mr Gilby would have collapsed if it had been in situ and utilised by Mrs Lyall as a hanging point.

Furthermore, it was the evidence of Mr Gilby, which was not challenged, that the Department, when it commissioned his firm to undertake the architectural work upon the Unit, did not "request any specific advice from the firm of an occupational health and safety kind concerning the well-being of patients." Further, it was his evidence that "at no time during the course of receiving instructions from the Department was the firm requested or asked to provide a design of the refurbishment to avoid hanging points." He contrasted this assignment with other design commissions received by his firm from the Department where specific instructions were received to avoid the creation of hanging points. He cited the psychiatric ward at the RHH as an example. He considered it "unlikely" that the "break free" specification was stipulated because of a request made by the Department but instead was specified upon the architect's initiative "as a matter of good practice architectural design."

I am satisfied on the evidence that it was not part of Gilby Vogus Architects' brief to design and oversee the construction of the Unit absent hanging points and its specification of a "break free" curtain rail was not a response to a direction or request of the Department but rather was a choice governed by reason of architectural design. In these circumstances it is my opinion that no criticism should be made of either the architect or the builder for not ensuring that the bathroom where Mrs Lyall died was fitted with a "break free" curtain rail.

In circumstances where I cannot be satisfied that a "break free" rail would not have supported Mrs Lyall and where, in any event, it was not part of the architect's brief to ensure the installation of such a rail, it would, in my opinion, be inappropriate and not available on the evidence to make any finding that any conduct on the part of Gilby Vogus Architects, Anderson Builders or any of their principals or employees contributed to Mrs Lyall's death.

A separate question is whether, in the interests of patient safety, the Unit should be free of hanging points. That is a subject I can now consider.

HANGING POINTS IN THE UNIT

I have cited above the opinion of Professor Currie that detoxification units should not have hanging points. This is because of the high incidence of patients affected by depression who, as a result, are at increased risk of self-harm or suicide. I accept this opinion. It is self-evident. However, I recognise the practical difficulty of designing a facility free of all potential hanging points. I recognise too that a detoxification unit is not a jail and there is a need, as an aid to patient rehabilitation, for the facility to be homely and user friendly. This leads me to recommend that the Department ensure that the Unit be free of all obvious and likely hanging points. However, I need to make it clear that by this recommendation it is not intended to advise that there be a total ban on all hanging points, both real and potential, as would, for example, be necessary in a jail accommodating indigenous Australians or a high dependency unit housing at-risk psychiatric patients. Further, I recommend that the Department ensure that it require its architects, to give consideration to environmental risk factors including hanging points when required to design and oversee the construction of any facility likely to be occupied by persons suffering from alcohol and/or drug addiction.

I acknowledge that since Mrs Lyall's death the Department, following an environmental risk audit of the Unit, has had its shower curtain rails removed.

RECOMMENDATIONS AND COMMENTS

1. It is my recommendation that the Alcohol and Drug Service put in place a formal procedure designed to ensure that as soon as reasonably practicable a full medical history be obtained upon each involuntary patient admitted to the Unit. Such procedure should include the need to be fully informed upon the patient's previous treatments and may require communication with family members and other medical treaters.

2. It is further recommended that the Alcohol and Drug Service adopt a practice to ensure that patients involuntarily admitted to the Unit undertake, within 48 hours of each admission, a formal psychological assessment to be carried out by a medical officer or properly trained nurse.

3. It is a further recommendation that the Unit have assigned to it a psychiatrist, available on an as needs basis to provide psychiatric services for its patients.

4. It is further recommended that the Alcohol and Drug Service put in place procedures to ensure the development and utilisation of a comprehensive treatment plan for each patient involuntarily admitted to the Unit. Such plan should incorporate the timely convening of a case conference involving all interested parties, the adoption of an in-patient plan for management of the patient's treatment and care and the development and adoption of a post-discharge plan providing for the patient's on-going treatment and its monitoring.

5. Evidence was received that since 2006 the Alcohol and Drug Service had received a significant increase in funding which had enabled it to develop and implement procedures within the Unit, to recruit personnel including a psychologist and counsellors and to improve its access to out-patient counselling services. However, it is my further understanding that no steps have been taken to evaluate the effect of these changes upon patient care and whether improved outcomes are being achieved. It was the evidence of Professor Currie that the unit under his management at St Vincent's Hospital aims to achieve for its patients a 60-70% abstinence from alcohol at five years post-detoxification. It is my recommendation that a similar standard be set for the Unit and that its performance be evaluated annually against that standard.

6. This inquest has necessarily been focused upon Mrs Lyall's care and treatment by the Unit. However, her medical history shows that prior to September 2006 she had sought treatment for her addictive illness in several other facilities, both public and private. A scanning of their records would indicate that none put in place a treatment regime incorporating those ingredients advised by Professor Currie. It is my recommendation that each of those facilities review their practices and procedures for the treatment of alcoholics and give consideration to incorporating those principles advised by Professor Currie.

7. It was the tenor of the evidence provided by Dr Reynolds that the standard of treatment recommended by Professor Currie, whilst in many respects desirable, was unattainable because of budgetary limitations. This is unacceptable. The alcohol industry, with all of its components, is a source of vast profit in this country. It also generates significant excises and other taxes. It is beholden upon the industry, governments and the community generally to ensure that properly funded and resourced facilities are available in this State to properly treat those persons who fall victim to alcohol's addictive qualities and whose health becomes seriously imperilled.

COMMENT UPON MR LYALL

I am satisfied upon the evidence that for the duration of their marriage Mr and Mrs Lyall had a loving and caring relationship. In its latter years, but more particularly during 2006, Mrs Lyall's excessive drinking imposed strains on the relationship but nevertheless Mr Lyall remained supportive of his wife and committed to assisting her in trying to manage and treat her alcoholism. It is a matter of real regret that neither the public nor private health services were able to provide both Mr and Mrs Lyall with that level of support which would have maximised Mrs Lyall's prospects of being successfully treated.

Formal findings required by section 28(1)(a) to (d) inclusive of the Coroner's Act 1995

I find that Jakyung Seo Lyall was born on 28 October 1974 and was aged 31 years. Mrs Lyall died in a bathroom of the Detoxification Unit located in the Carruthers Building at St Johns Park in New Town at about 7.30 pm on 19 October 2006. Her death occurred as the result of Mrs Lyall intentionally hanging herself with an electrical cord from a shower curtain rail. I find the formal cause of death, as opined by the State Forensic Pathologist, to be "hanging during treatment for alcohol and benzodiazepine withdrawal."

I conclude by extending my sincere condolences to Mr Lyall and to all members of Mrs Lyall's family.

Dated this 24 day of February 2012.

Rod Chandler
Coroner