Coronial
ACTmental health

Inquest into the deaths of ANTHONY LEIGH BEARHAM, NICOLA JOY FISHER, CHRISTINE BELLE DOUCH andKEN ALEXANDER LUCAS

Deceased

Anthony Leigh Bearham, Nicola Joy Fisher, Christine Belle Douch, Ken Alexander Lucas

Coroner

Coroner Hunter

Date of death

2015-2016

Finding date

2021-03-04

Cause of death

Bearham: hypoxic brain injury from hanging; Fisher: asphyxiation from hanging by dressing gown belt; Douch: haemothorax and blunt chest injuries from fall from height; Lucas: global cerebral hypoxia from hanging

AI-generated summary

Four inpatient suicides occurred at The Canberra Hospital mental health units between January 2015 and November 2016: three by hanging and one by jumping. The coroner found systemic failures including inadequate ligature risk mitigation, poor observation procedures, failure to properly search for dangerous items, inadequate staff training, and communication failures between clinical staff and investigators. Key issues included use of non-ligature-proof door handles, failure to detect a dressing gown belt used as ligature, missed ARC observation changes, and staff reluctance to cooperate with police investigations. Recommendations addressed training, policies, technological safeguards, and accountability systems.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

psychiatryemergency medicineintensive care

Error types

diagnosticsystemdelaycommunicationprocedural

Clinical conditions

severe depression with suicidal intentpsychosisparanoid schizophreniachronic painsystemic lupus erythematosusopioid dependenceacute kidney and liver impairmentanxiety

Contributing factors

  • inadequate ligature point mitigation
  • poor door handle design
  • failure to remove dangerous items from patients
  • inadequate observation procedures
  • failure to communicate ARC score changes
  • inadequate staff training on risk assessment
  • failure to reassess suicidal risk
  • poor handover procedures
  • bed block and insufficient acute beds
  • understaffing and fatigue

Coroner's recommendations

  1. Review MOU between TCH and AFP to clarify Police access to staff witnesses in coronial matters
  2. Review TCH Operational Procedure 'When Death Occurs' to encourage staff engagement with Police and clarify witness options
  3. Review policy and procedure for searching patients for dangerous items with clear procedures for when resistance is met
  4. Review technological equipment for monitoring at-risk patients such as pulse oximeters and CCTV in general areas
  5. Review training on 'at-risk observation' policy to ensure staff understand reasoning and importance of adherence
  6. Finalise MHSSU Operational Procedure as soon as practicable
  7. MHJHADS consult with staff and review training packages for fitness and appropriateness
Full text
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