Mount Gambier hospital patient Mathew George Paxford absconded twice before death, inquest hears

A mental health patient absconded from hospital twice before he took his own life on the ward. An inquest is being held into the circumstances surrounding his death.

A nurse who was caring for a man who took his own life in his hospital room said she was more concerned he would abscond than harm himself on the ward, an inquest has heard.

Mathew George Paxford, 27, died in the Mt Gambier hospital on March 24, 2016, after he was admitted to the hospital’s six-bed mental health unit a day earlier.

During his stay he had absconded by jumping a courtyard wall to go for a jog around the hospital and on another occasion had left and returned to his family home.

State Coroner David Whittle is holding an inquest examining the circumstances surrounding his death.

Counsel assisting the coroner, Stephen Plummer, said the inquest would consider “two significant coronial issues” including the supervision of Mr Paxford after he revealed he was having suicidal thoughts, and the existence of the method which he used to take his life – which still exists at the hospital.

He said some safety improvements and changes to observation protocols had been made since Mr Paxford’s death, including constant patient monitoring until a risk assessment deems them suitable for half hourly checks.

Registered nurse Jacqueline Campbell was caring for Mr Paxford on the day he died.

She told the inquest Mr Paxford was subject to hourly checks, but his condition appeared to be deteriorating and he had reported having “thoughts of ending his life” so she left his room shortly after 7pm to ask another nurse to authorise a “Level 1 Inpatient Treatment Order”.

At the time that order meant Mr Paxford was subject to checks every 15 minutes instead of hourly.

When she returned to his room about 20 minutes later, she found Mr Paxford dead.

“If for one minute I thought the risk was imminent I wouldn’t have left the room. I just wouldn’t,” she said.

“I honestly believed that in the hospital he was in a safe place.”

Registered nurse Jacqueline Campbell outside the Coroners Court. Picture: NCA NewsWire / David Mariuz

Mrs Campbell said she believed the chance of Mr Paxford absconding, as he had twice already since his admission a day earlier, was a higher risk.

“I was terrified he was going to go over the wall,” she said.

“I honestly believed he was going to abscond, even now to this day.”

She said she believed it was more likely Mr Paxford would abscond and self harm, rather than taking his own life at the hospital.

Mrs Campbell said she had attempted to discuss Mr Paxford’s worries, which included that he said “his head was too busy” but “he just wasn’t willing to expand on it”.

The inquest heard Mr Paxford’s mental health had been declining in the months before his death, and he had become paranoid someone would harm his family and that he needed to die to save them.

Mrs Campbell said he had been provided with medication to ease his anxiety and had expected it would help.

The inquest heard that while Mrs Campbell was checking on Mr Paxford, the other nurse on the ward had taken a phone call from his mother, Amanda Paxford, who told the nurse she felt her son had been “saying his final goodbyes” in a separate phone call minutes earlier.

Mrs Campbell said some changes had been made at the hospital since Mr Paxford’s death, including the removal of locks on bathroom doors and sealing of potential ligature risks, but other risks remained.

She said the particular method of suicide relating to Mr Paxford had not been removed.

The inquest is continuing.