Inquest hears of supervision before Kelvin Forrest’s fatal hospital fall

Kelvin James Forrest, who had Down syndrome and symptoms of dementia, had one-on-one supervision for a brief period after being found on a nearby road outside Byron Central Hospital, the inquest into his death has heard.

A man living with a disability and symptoms of dementia had one-on-one care for a brief period before his death but it was discontinued, a coronial inquest has heard.

Deputy State Coroner Harriet Grahame is this week presiding over the inquest into the 2018 death of Kelvin James Forrest at Byron Central Hospital.

The inquest is being heard in Ballina.

Clinical notes detail Kelvin’s wandering

The inquest has heard 53-year-old Kelvin, who had Down syndrome, had one-to-one supervision on July 26, 2018, a practise known as being “specialled”.

It was noted by nurses throughout much of his 11-day stay that Kelvin was prone to wandering around the corridors of the hospital and even leaving the facility.

This included him being found at the roundabout outside the hospital on Ewingsdale Road on the morning of July 26.

He passed away at the hospital on July 28 after climbing over a balcony, onto a roof and falling, the inquest has heard.

Kelvin was taken to the emergency department after his fall and CPR was conducted for an extended period, the inquest has heard.

Confusion over NDIS liaison and a complex situation in the ward

The inquest has also heard an NDIS transition manager was employed by Northern NSW Local Health District at the time of Kelvin’s death, but healthcare workers have given evidence they were not aware of this role.

Complexities between the care of Kelvin and another patient, a 19-year-old with acute autism who was also in the inpatient unit, have also been aired.

Part of the Inpatient Unit at Byron Central Hospital. Picture: Cathy Adams

Robert Becher, who worked in health and security assistance at the hospital at the time, told the inquest on Tuesday the glass door to the inpatient unit balcony had been kept unlocked during the day to help manage the behaviour of a severely autistic patient.

He recalled that patient, who had constant supervision and had damaged some hospital property, had been at the hospital for “a considerable length of time”.

“(It was) months rather than weeks,” he said.

The inquest heard that 19-year-old, who cannot be named, was not in the hospital for a medical reason.

“We were told he was waiting for suitable accommodation,” Mr Becher said.

“I believe they were renovating a residence in the Ballina area or Lismore area … it was taking some time.

“He was being housed in the ward.”

Byron Central Hospital.

Mr Becher recalled a time when Kelvin, who was reported to be disorientated spent a long time at the balcony door, saying he wanted to go home.

It took a long time for staff to direct him away from that area.

Observations of Kelvin

Registered nurse Nerida Newlands told the inquest she was aware Kelvin had “wandered outside the building” at some stage but wasn’t aware of the full details of that incident.

Ms Newlands said if she had been aware of the full details, in the context of Kelvin’s Down syndrome and dementia symptoms, that would have been cause for alarm in her mind.

She said this may have been enough for ongoing one-to-one observation, depending on a managerial determination.

But there was a perception Kelvin had settled after his time under full observation, the inquest heard.

“We were managing within the staff that we had on that shift,” she said.

“Had we not had the staff to assist with Kelvin, I may have considered escalating to a special.”

The inquest is expected to run throughout the week. Picture: Liana Boss

Ms Newlands said when she began her shift, handover information stated Kelvin was “not approved by management as needing a special”.

Tracey Brooke was the acting deputy director of nursing at the time.

She was not on duty at the time of his fall but was called in on her day off in the aftermath.

The inquest heard recommendations for Kelvin to have higher supervision were made in clinical notes on numerous occasions, in part because he was frequently “confused and wandering”.

But the parameters of the care required were not set out.

Ms Brooke said it was not clear why this was not explained in more detail.

She was the health worker who signed off on Kelvin’s one-on-one observation that was in place from 4pm to midnight on July 26.

“I don't recall it being escalated to myself, the concerns about him wandering,” she said.

“To have a special … it had to be reviewed every shift.”

Ms Grahame said she could see “significant risk” in that Kelvin was found on the road and the following day, he was not being constantly supervised.

Counsel assisting the coroner, Ragni Mathur, suggested professionals had looked at a finite period, including when Kelvin’s wandering had settled, rather than “reflecting back on the pattern” of his behaviour throughout his hospital stay.

“What are your reflections on the whole treatment of Kelvin … whilst he was in the inpatient unit?” Ms Mathur asked.

Ms Brooke replied she would rarely knock back a request for a patient to be specialled.

“I don’t know if it was more of a break in communications,” she said.

In the emergency department

After hours nurse manager Emma Smith told the inquest “extended” CPR was conducted on Kelvin in the emergency department following his fall. “CPR continued for about 45 minutes,” she said.

The inquest heard during this time, hospital staff relayed to Kelvin’s brother, John, that the patient was in a “fairly critical state”, that CPR was ongoing but the prognosis was not good.

A short time later, Kelvin passed away.

The inquest is ongoing.