Inquest into the Death of Jordan James WILLIAMS

Contributing factors

• inadequate supervision and observation of high-risk patient
• failure to confine patient to room after first successful absconding
• inadequate courtyard fence height allowing patient to scale and escape
• staffing shortages preventing allocation of dedicated psychiatric nurse (1:1 special)
• use of untrained security guards instead of psychiatric nurses for patient observation
• failure to communicate to clinical staff that patient was found near railway tracks after first absconding
• allowing access to courtyard after demonstrated ability to escape despite high documented risks
• bed pressure resulting in admission to general ward rather than mental health unit
• patient psychotic state impairing judgment and understanding of consequences
• inadequate handover and communication between security staff and nursing staff
• lack of contemporaneous clinical documentation creating gaps in care record

Coroner's recommendations

1. WACHS should take immediate steps to ensure remediation works to raise the height of the boundary fencing of the courtyard attached to the mental health unit at Kalgoorlie Health Campus are urgently completed, making this an absolute priority
2. WACHS should approach the lessee of the railway line at the rear of KHC and advise that the chain link fence running along the railway line needs urgent inspection with a view to upgrading the fence as soon as reasonably practicable to properly restrict access to the railway tracks in the vicinity of KHC
3. WACHS should urge the Department of Finance to fast-track the proposal to construct a purpose-built mental health facility at Kalgoorlie Health Campus so that construction can start as soon as possible, and undertake detailed planning to ensure the new facility is appropriately staffed by mental health and allied health professionals