Coronial inquest findings delivered in 2018 Byron Bay hospital death

The Deputy State Coroner has praised the family of a Byron Bay man with Down syndrome and dementia who fell to his death for highlighting the “need for change” in the local hospital system.

The tragic death of a Byron Central Hospital patient was “a wholly preventable tragedy” a NSW coroner has ruled.

Kelvin Forrest, 53, was a patient at Byron Central Hospital for 11 days leading up to his death at the facility on July 28, 2018.

His carer found him unwell on the floor of his home before his hospital admission.

On July 26, Kelvin was found wandering at the roundabout outside the hospital and his death came after he climbed onto a roof near the inpatient unit balcony, then fell to the pavement of the loading dock below.

Kelvin, who had Down syndrome and dementia, was taken to the emergency department but after extensive CPR he died as a result of the fall.

A five day inquest into the circumstances and safety systems in place at the time of Kelvin’s death took place in November 2021 at Ballina and coronial findings have recently been released.

The inquest into the 2018 death of Byron Bay man Kelvin Forrest at Byron Central Hospital was heard in Ballina Coroner's Court in November 2021. Picture: Supplied

The inquest heard from medical staff and Kelvin’s brother John Forrest who described Kelvin’s fulfilling life volunteering and being the “centre of attention” at family gatherings.

During the course of the inquest evidence was given that Kelvin’s propensity to wander was apparent from before his admission and that staff were urged to supervise him 24/7.

Deputy State Coroner Harriet Grahame found “Kelvin’s behaviour, from the time of admission, at Byron Central Hospital indicated a need for closer supervision than he received”.

She noted there was “a failure to properly understand the nature and causes of Kelvin’s wandering” which led to “inadequate managements of the risks involved in his care”.

The balcony door which Kelvin is believed to have exited was unlocked at the time to accommodate the needs of the young autistic patient who became upset if he found the door to be locked – something which Ms Grahame noted was a “clear risk” not factored in.

Acting chief executive of the Northern NSW Local Health District Lynne Weir was present throughout the inquest into the death of Kelvin James Forrest at Byron Central Hospital. Picture: Liana Boss

The inquest had heard that following the tragedy Northern NSW Local Health District made a number of hospital changes including introducing a new policy concerning clinical handovers, clearer information about the risk of wandering, and better nurse risk discussion.

Ms Grahame said this was a demonstration of the health district’s commitment to addressing safety gaps.

The Deputy State Coroner also pushed for further help for National Disability Insurance Scheme participants to access urgent funding reviews.

The inquest had heard the newly National Disability Insurance Agency was privy to “countless emails” between Kelvin’s brother, John, United Disability Care (known at the time as AccNet) and sometimes the National Disability Insurance Agency regarding “an urgent review of Kelvin’s care needs and funding” between March and July.

Ms Grahame accepted the NDIA had since streamlined urgent reviews but acknowledged more could be done.

Three recommendations were made following the close of the inquest, including amending admission procedure at Byron Bay Central Hospital.

“I acknowledge that the pain of losing a loved one in these circumstances is profound,” she said in her findings.

“I greatly respect Kelvin’s family’s decision to participate in these difficult proceedings to highlight the need for change.

“Kelvin was a trailblazer in many ways and one hopes NNSWLHD continues to reflect on ways of improving service for patients, such as Kelvin, who experience disability.

“In closing, I acknowledge Kelvin as a shining example to us all in his obvious capacity to find joy and meaning in life through love of family and engagement with his community. His example is not forgotten.”

The coroner’s court issued three recommendations at the close of the inquest including amending hospital admission so explicit consideration is given as to whether the patient has a disability or is on the NDIS and then making appropriate referrals; that the health district implement the Revised Algase Wandering Scale to assist those with a history of wandering; and that all casework staff at United Disability (ACCnet21) complete mandatory training with a NDIA representative surrounding funding.