Coroner finds Mildura Base Hospital breached Matthew Luttrell’s rights

Yorta Yorta man Matthew Luttrell took his own life the day after his discharge from Mildura Base Hospital in 2018. Now a coroner has found the hospital breached his human rights.

Mildura Base Public Hospital.

A coroner has found that a north Victorian hospital breached an Indigenous man’s rights and could have prevented his suicide the day after his discharge from a mental health ward.

Matthew James Luttrell, 43, committed suicide on November 13, 2018, one day after his departure from Mildura Base Hospital.

The Yorta Yorta man grew up in Shepparton and Kyabram and was said to have been a “larrikin” with a “kind, bubbly” character.

He moved to Mildura in 2015.

Mr Luttrell had a number of mental conditions, including borderline personality disorder and a history of suicidal thoughts and actions.

He was said to have struggled getting help because he did not wish for his ailments to become well known.

In 2018, Mr Luttrell was directed to Mallee District Aboriginal Services, where he was assigned a case worker to assist in his treatment.

In November that year, Mr Luttrell threatened suicide following a relationship dispute.

When a family member called emergency services, Mr Luttrell left the home and headed for the mental health unit of Mildura Base Hospital of his own volition.

Mr Luttrell told hospital workers he intended to end his life, and was admitted voluntarily into the inpatient unit.

The next morning, a nurse noticed Mr Luttrell was “difficult to engage, uncooperative, angry, and frustrated” and that he expressed “hopelessness and helplessness” and suicidal intentions.

The MDAS worker assigned to Mr Luttrell visited and helped him with some personal possessions, but left when Mr Luttrell told him to “f – k off and not come back”.

He became more agitated about certain eating arrangements and accidentally dropped his lunch tray in the hospital’s courtyard before beginning to self-harm.

The police were called and Mr Luttrell was physically restrained and sedated.

In her findings handed down on Tuesday, Coroner Audrey Jamieson said the “limited” knowledge and training of staff were displayed during this incident, especially regarding de-escalation techniques.

Although she said she did not expect hospital workers to put themselves in physical danger during what they perceived to be an armed threat, Ms Jamieson noted that the police officers managed to communicate effectively with Mr Luttrell “just using conversation” by shouting through glass and helping him have a cigarette.

Nevertheless, later that afternoon Mr Luttrell was “more settled” and denied having intentions to hurt himself or others.

At that point, he was said to have been “not acutely suicidal” despite his previous statements and actions.

Mr Luttrell was then given two options for treatment, both of which Ms Jamieson said were “ill-considered”.

Neither option concurred with Mr Luttrell’s own desires as he was deemed “too risky” to other patients and hospital staff.

The hospital did not get in touch with MDAS about Mr Luttrell’s discharge, only making a phone call about his threats to the case worker the following day.

Ms Jamieson said Mr Luttrell’s “challenging presentation” affected his treatment and the hospital staff’s assessment of risk.

His son was also not called despite his being a contact on the hospital’s file.

Mr Luttrell left the hospital on foot for his son’s home.

The next morning, the son and his partner left for work with Mr Luttrell asleep on the couch.

The son returned home after midday and found his father dead.

Mr Luttrell had left a handwritten suicide note in a duffel bag in the living room.

Coroner’s findings

Ms Jamieson found that Mildura Base Hospital “demonstrably” breached Mr Luttrell’s rights.

She said the hospital failed to seek cultural support or more information from case workers or family members about Mr Luttrell’s situation, which would have allowed the hospital to act in a more informed and culturally-appropriate manner.

Ms Jamieson said the hospital’s decision to use “restrictive intervention” was inconsistent with the Mental Health Act and Mr Luttrell’s rights to liberty and physical integrity.

Mr Luttrell was not, for instance, asked to take medication orally.

Ms Jamieson said Mr Luttrell’s seclusion on November 12 was “unlawful” and a “clear breach” of legislation.

Of particular importance was the hospital staff’s note that should Mr Luttrell return after his departure, he should not be readmitted “due to the unacceptable risk posed to patients and staff”, and that instead, the police should be called.

Ms Jamieson said that although Mr Luttrell’s suicide might not have been “preventable in perpetuity”, it could at least have been prevented as of November 13.

She said there were “many opportunities missed to intervene in the course of events immediately preceding his passing”.

There were no adverse findings about staff, and the hospital was said to have already made improvements to its systems and taken on a new Aboriginal Health Director.

Ms Jamieson’s recommendations included the concrete establishment of information-sharing agreements between Mildura Base Hospital and MDAS, well-resourced cultural awareness training in the hospital’s mental health unit, consultation with the Aboriginal Health Director on all hospital policies, better training for handling patients with borderline personality disorder, and the clarification of certain mental health care policies.