Inquest hears of ‘significant impact’ of Kelvin Forrest’s hospital death

“A lot of work” has been done to improve patient safety at Byron Central Hospital since a 53-year-old man with Down syndrome and dementia fell to his death, an inquest has heard.

An inquest into the 2018 death of Byron Bay man Kelvin Forrest at Byron Central Hospital is being heard in Ballina Coroner's Court this week. Picture: Supplied

The tragic death of a Byron Central Hospital patient has prompted “a lot of work” on patient safety, according to the facility’s director of nursing.

Kylie Wilhelm’s comments came as she gave evidence at a coronial inquest into the death of Kelvin James Forrest, 53, being held in Ballina this week.

The inquest has heard Kelvin lived with Down syndrome, had a preliminary diagnosis indicating he had symptoms of dementia and was admitted to the hospital after being found unwell on the floor of his home by his carer in July 2018.

He spent 11 days at the hospital before he died and during his time there, clinical notes repeatedly mentioned his propensity to wander around the hospital as well as leaving the facility.

He was found near the roundabout outside the hospital on the morning of July 26.

He died two days later after entering a balcony, climbing onto a roof and falling onto the pavement of a loading dock area.

Byron Central Hospital.

He was found by a health and security assistance worker and rushed to the emergency department, where CPR was conducted for about 45 minutes.

But he could not be revived.

Ms Wilhelm was not working at the hospital at the time of the incident but became employed there in late 2018.

She was however able to reflect on the impact of Kelvin’s death.

“This case has had a significant impact on the nursing staff,” Ms Wilhelm said.

“They have reviewed their processes, the way they work.

“They have been working very hard to maintain the safety of patients.”

She said staff had contributed to research and advocated for patient safety across the district during that time.

The first two days of the inquest heard evidence from medical staff including nurses, a nurse in a managerial role and health and security assistance staff.

It heard Kelvin was “specialled”, meaning he had one-on-one observation, for a brief period on July 26 after he was found near the roundabout.

But there was no documentation to suggest that observation continued past midnight, or to indicate any formal process of reviewing its ongoing necessity.

Ms Wilhelm told the inquest there had been processes implemented by the health district since then.

She said that included a multidisciplinary “huddle” where “specialled” patients and other risk factors were frequently reviewed.

Byron Central Hospital.

Delays in escalating funding changes

The inquest also heard evidence from Angela Hartley, a support co-ordinator at United Disability Care, which was known as AccNet in July 2018.

Ms Hartley first came in contact with Kelvin’s case in March of that year.

She told the inquest her role involved helping National Disability Insurance Scheme participants to “utilise their funding” to “meet their goals”.

The inquest heard Ms Hartley was aware of “a deterioration in Kelvin’s presentation” in May.

He was flagged for a funding review in March but the inquest heard Ms Hartley only sent a key piece of correspondence about this to the National Disability Insurance Agency in June.

Counsel assisting the coroner, Ragni Mathur, queried why in the interim months Ms Hartley didn’t explicitly tell Kelvin’s brother, John Forrest, how important medical expert reports would be to bolster his chances at more funding.

“Would it be fair to say that you understood a specialist opinion was more or less mandatory in terms of having any hope of the NDIA (approving) an increase in funding to a client?” Ms Mathur asked.

“It would be fair to say the essential nature of that specialist opinion was not really drawn to John Forrest’s attention?”

Ms Hartley agreed with the points but offered little clarity on why those details weren’t explained to Mr Forrest.

Ms Hartley said although the National Disability Insurance Agency recommended quarterly monitoring reports to support her application, they weren’t available and there was no evidence of steps taken to query with the agency how the relevant information could be best addressed.

She said she had been advised those reports were of limited value because in the past, agency staff didn’t read them in their considerations.

When pressed on that point by the lawyer representing the agency, Ms Hartley said she could not recall which individual told her this.

“From experience we found not a lot of reports were thoroughly read,” she said.

“We were having more outcomes having that discussion at the planning meeting.”

Ms Hartley said wait times for appointments and funding constraints were hurdles to obtaining a vital occupational therapist report.

“The funding Kelvin had been allocated in his NDIS plan was allocated already prior to my engagement,” she said.

“Some of that funding would be used for an OT report (but) because there was no funding available I would not have made that recommendation.”

Deputy State Coroner Harriet Graham expressed concern about this.

“I’ve got to say that sounds like the most terrible Catch 22 situation,” she said.

“He’s got to have the report to get the funding, but he doesn’t have the funding to get the report.”

The inquest heard an occupational therapist report was prepared while Kelvin was in hospital, prior to his death.

Another essential report, from a geriatrician confirming his dementia diagnosis, was completed earlier in July.

Ms Hartley was asked by Ms Mathur to reflect on her contribution to Kelvin’s situation.

“I was trying my best to provide support to a family … to get an outcome and we were not able to achieve that,” she said.

“I based what I was doing on what I knew at the time.”

The inquest is ongoing.