Inquest into the Death of Hudson

Contributing factors

• Inadequate nursing observations despite 30-minute observation order
• Failure to sight and verify patient safety as required by close observation guidelines
• Unsecured ward with multiple unmonitored exits allowing undetected departure
• Failure to escalate to involuntary patient status despite repeated suicide ideation and deteriorating mental state
• Inadequate psychotherapy provision despite disclosure of sexual abuse and treating team agreement to provide it
• Ward D20 not an authorised hospital under Mental Health Act unable to house involuntary patients
• Poor ward design preventing effective patient monitoring
• Unreliable medication chart entries and practices

Coroner's recommendations

1. The Health Department should conduct a review of the process for providing medications to mental health patients to ensure that patients receive medications at about the times ordered and the time of provision is accurately recorded in medication charts
2. The observations chart should be altered so that the time column does not contain pre-entered times, but the nurse should enter the actual time when the patient has been observed
3. An additional column should be inserted in the observations chart to record actual observations made of the patient by the nurse conducting the observations, such as whether the patient was agitated, morose, cheerful, talking or appeared dazed or over-medicated
4. A copy of the Nursing Guidelines relating to nursing observations should be retained at the same location where the observations charts are located on the ward, and the observations chart should be amended by adding a brief reference to the importance of ensuring that on close observations the designated nurse must be able to satisfy himself or herself that the patient is safe
5. The Health Department should review the practicalities associated with conducting high quality observations of at risk patients to ensure consistency in nursing practice and to reduce unnecessary inconvenience in conducting and recording observations
6. In all future plans for mental health units, there should be provision for authorised beds and the construction of units should be such that staff are able to monitor all persons entering or leaving the ward