Inquest begins into Byron Central Hospital death of Kelvin Forrest
A coronial inquest into the tragic death of 53-year-old Down syndrome man has heard of his rapid decline after the death of his mother, who was regarded as his “rudder”.
Picture: Tracey Nearmy
Byron Shire
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A man with Down syndrome frequently wandered around a Byron Bay hospital before he climbed onto a balcony and roof and suffered a fatal fall, a coronial inquest has heard.
Kelvin James Forrest, had been an inpatient at Byron Central Hospital for 11 days when he died after a falling from a roof at the facility.
The inquest into his death began in the Coroner’s Court in Ballina on Monday.
In her opening address, counsel assisting the coroner, Ragni Mathur, said Kelvin climbed over a balcony and onto a roof prior to the fall on July 28, 2018.
He was found by a hospital worker who called for help, but Mr Forrest could not be saved.
The inquest is set to consider the policies and procedures around urgent reviews of National Disability Insurance Scheme funding for clients in crisis.
“It is hoped that this inquest will shed some light into the matters that affect a presentation such as Kelvin’s,” Ms Mathur said.
She said the inquest would also consider whether or not there were inefficiencies in the care of vulnerable people in the community.
Kelvin’s ‘incredibly social’ life
The inquest heard Kelvin lived a full life.
His parents were keen on him receiving and education and becoming a functioning member of society.
He lived at home until his early 20s, then moved into a group home before living independently in central Byron Bay from 2014.
Ms Mathur said Kelvin was known as “a very empathetic man” and “incredibly social”.
He enjoyed dancing at the top pub in his early years.
Later on, he was a regular at the RSL.
He worked at a plant nursery and volunteered for the Salvation Army, Meals on Wheels and other organisations.
Regular phone calls with his mother were a constant in Kelvin’s life until his elderly parents moved into a nursing home in October 2017.
It took months for their landline phone to be connected.
The inquest heard when Kelvin’s mother passed away in January 2018, he lost “his rudder”.
“After the death of his mother it appears Kelvin began to decline and deteriorate at a rapid pace,” Ms Mathur said.
The inquest is expected to hear psychiatric evidence of the “profound upheaval” and its toll on Kelvin in the months that followed.
During this time, those close to him became increasingly concerned about his welfare, Ms Mathur said.
His carers at AccNet became more concerned about his ability to keep living alone by March, 2018 and they began a process of seeking more funding to support a higher level of support.
A review of his National Disability Insurance Scheme funding was submitted by the organisation in mid April.
Kelvin was found wandering the streets alone at night in late May and on May 31, he was found standing in the middle of a street unaware of the traffic or the dangers.
His support worker, Angela Hartley, submitted an application through the National Disability Insurance Agency to fund full-time care in a group home.
The same month, Kelvin was found to have symptoms of dementia and a geriatrician recommended increased supervision, up to 24 hours a day.
Ms Mathur said there were “countless emails” between Kelvin’s brother, John, AccNet and sometimes the National Disability Insurance Agency regarding “an urgent review of Kelvin’s care needs and funding” between March and July.
Kelvin’s hospital stay
Kelvin’s hospital admission came after his carer found him at home, on the floor, “cramped in pain and hypothermic” on July 17, Ms Mathur said.
During his stay at the hospital, Kelvin was found wandering near a roundabout on the public road.
Hospital staff observed him wandering around the hospital on numerous other occasions.
The evidence so far
Mark Hensby, a health and security assistant at the hospital, appeared as a witness on the first day of the inquest.
Mr Hensby was the one who found Kelvin after his fall.
“I established Kelvin was alive when I found him,” he said.
“He made attempts to stand up.”
Mr Hensby said he recognised Kelvin because he’d dealt with him during standard patient care on the ward.
He called for help and Kelvin was then taken into the emergency department.
Mr Hensby said his role sometimes involved one-on-one observation of patients, including another patient who was in the same ward.
He could not recall whether that took place while Kelvin was also a patient there.
Detective Acting Sergeant Gary Sheehan of Tweed Byron Police District attended the hospital after Kelvin’s death.
Det Sheehan sought access to all CCTV footage available, but he “wasn’t able to see Kelvin leave his room at any stage” on the available footage, due to the placement of cameras.
Det Sheehan said he was told glass doors leading to a balcony were often kept unlocked because of the behaviour of another patient in the ward who was “quite aggressive sometimes” and was “constantly wanting to get through the glass doors”.
The inquest heard police had attended a Byron Bay boutique in early June that year when Kelvin refused to leave.
He had believed one of the staff members was his carer.
John Forrest had tried to obtain information from police about this incident, while appealing to have his brother’s care funding reviewed.
Det Sheehan said while NSW Police had some memorandums of understanding with organisations like NSW Health, he wasn’t aware of one existing between police and Kelvin’s care provider.
This meant it was difficult for police to share information with John Forrest over the phone, he said.
He cited privacy laws among other issues.
An officer who took photos of the scene, including marks on the roof above where Kelvin was found, also appeared as a witness.
The inquest, before Deputy State Coroner Harriet Grahame, will continue throughout the week.
A range of nurses are expected to give evidence on Tuesday.
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