Inquest into suicide deaths of Mark John Furlan and Richard John Miller will explore possible failings at RAH mental health ward

A coronial inquest will explore how two men took their own life despite being in the RAH’s mental health ward – and whether they were watched closely enough.

A depressed father detained in the mental health ward at the Royal Adelaide Hospital died by suicide during a 35-minute period where he was not observed by a nurse, an inquest has heard.

State Coroner David Whittle is holding a coronial inquest that will explore how two patients, Mark John Furlan and Richard John Miller, had the means to take their own life while they were under inpatient treatment orders at the RAH.

Each death occurred in Ward 2G, in the mental health ward, about three years apart.

Mr Furlan was admitted to the ward after work stress had caused a deterioration of his mental health over a three-month period.

He was suffering psychotic depression and having suicidal ideations.

The inquest heard that on February 25, 2018, on the morning Mr Furlan took his life, he was supposed to be under 15-minute observations.

Mr Furlan was last observed by a nurse at 11.10am that morning and not attended to again until 11.45am when he was found hanging from the ensuite door in his room by his own hooded jumper.

After 24 minutes of resuscitation Mr Furlan began breathing again, however after two days in intensive care, brain death was confirmed.

Counsel assisting Sally Giles told the inquest the ligature point Mr Furlan used, the ensuite door, had been identified months before his death.

“The reason for the existence ... of the ensuite door ligature points and others will be explored,” he said.

An ambulance outside the Royal Adelaide Hospital. Picture: NCA NewsWire

Mr Miller was transferred to Ward 2G of the RAH from the Adelaide Remand Centre in June 2021, after a relapse of psychosis.

He was placed on a level 2 inpatient treatment order and was awaiting transfer to James Nash House.

The inquest heard he was “acutely psychotic” and expressing suicidal ideations just days before his death occurred.

Mr Miller was last seen conscious at 10.45am on July 15 at the nursing station before he returned to his room and closed the door.

Ms Giles told the inquest a nurse reported he looked through the door at 11.02am and saw Mr Miller lying on his bed facing away from the door.

The nurse reported he could see Mr Miller breathing.

When the nurse returned to the room sometime between 11.15am and 11.20am, Mr Miller was found unresponsive.

A doctor was called and a ligature was observed around his neck concealed a piece of clothing.

Attempts were made to revive Mr Miller, however he was pronounced deceased at 11.55am.

Ms Giles said the inquest would also endeavour to explore the use of patients’ own clothing in the unit.

“A hooded jumper had some involvement in each of Mr Furlan and Mr Miller’s deaths,” Ms Giles said.

“The appropriateness of inpatients on inpatient treatment orders being left alone with such items of clothing will be considered.”

The inquest will also examine the policies and reporting methods around observations of patients admitted to the ward.

State Coroner Whittle will attend the RAH for a view of Ward 2G on Wednesday afternoon.

The inquest continues.