Inquest into death of Mathew George Paxford recommends review of toilet doors in mental health units

Toilet doors in one SA hospital’s specialist ward have been removed after a man’s death – and it could happen across the state.

Toilet doors in acute mental health wards across the state should be reviewed and modified to prevent suicides, the State Coroner says, in the wake of a young man’s death at Mount Gambier Hospital.

Mathew George Paxford was 27 when he took his life on March 24, 2016.

State Coroner David Whittle also heard of another case at the same hospital in 2021 where another similar suicide attempt was thwarted only by swift medical intervention.

The findings of an inquest into Mr Paxton’s death, handed down on Friday, found his mental health had been in decline in the preceding days.

Mr Whittle found while it was unclear whether Mr Paxford’s death was ultimately preventable, he should not have been left alone in a room.

The inquest heard Mr Paxford voluntarily admitted himself to the hospital’s mental health ward with the help of his family.

The Mount Gambier Hospital. Picture: Jessica Ball

The next day, he left the hospital by jumping over a wall and went home.

He was taken back to the hospital in a distressed state, bidding his parents goodbye in a way that gave them great concern.

A nurse became worried enough about Mr Paxford’s state of mind that she left the room, closing the door behind her, to start the process of having him detained under an inpatient order.

The nurse later told the inquest that she closed the door because she was concerned Mr Paxford would try to leave the hospital again.

In the 10 to 20 minutes Mr Paxford was left alone in the room, he took his own life using a door adjoining the toilet.

Mr Whittle found Mr Paxford should not have been left alone in the room.

He said while the parts of the doors in the mental health ward at the hospital had been modified in the aftermath of Mr Paxford’s death, a decision had been made to keep them in place.

On July 13, 2021, another patient tried to take their own life in a similar way.

Mr Whittle said the approach of balancing the risk of suicide with the concerns for privacy were “unacceptable” when the consequences could be so devastating.

As a result, all en suite doors have been removed in the Mount Gambier Hospital mental health ward with new doors set to be delivered soon.

Mr Whittle recommended all en suite doors in acute mental health wards across the state should be reviewed and modified if needed to prevent further deaths.