Coroner calls for new mental health facility

The death of a man in a mental health unit has prompted a call for a new facility to better care for chronically ill people suffering mental illness.

The Spencer Clinic located at the North West Regional Hospital at Burnie.

THE death of a man in a mental health unit at the North West Regional Hospital has prompted a call for a new facility in the region to better care for chronically ill people suffering mental illness.

Nigel Douglas Roberts, 55, died in Spencer Clinic at the Burnie hospital in 2016 from cardio-respiratory arrest due to mixed prescription drug sedation in the presence of advanced emphysema and acute bronchopneumonia.

Coroner Rod Chandler said Mr Roberts’ schizophrenia was being treated with clozapine and it was known he suffered from COPD.

He found Mr Roberts’ behaviour while in hospital necessitated pharmacological restraint and these factors together exposed him to the risk of respiratory depression.

“The evidence shows that the medical staff involved in Mr Roberts’ care were alert to the risk of this outcome and it was thus incumbent upon them to take all possible steps to minimise this risk,” he said.

“This included the need for a strict regime to be in place to monitor Mr Roberts, most particularly with respect to his respiration. Unfortunately this did not occur with his otherwise preventable death being the consequence.

“It was, in my opinion, insufficient to simply observe at 10- to 15-minute intervals that Mr Roberts was present and safe. Instead the monitoring should have included at the very least the taking and charting of his respiratory rate.”

Mr Roberts was living at the Karingal aged care home in Devonport before he was admitted to hospital.

Mr Chandler found Karingal did its best to provide Mr Roberts, for the duration of his residency, with a safe and caring home.

“However, Karingal is in essence a facility designed, equipped and staffed to provide residential care for the elderly. It is not suited to the care of younger persons who suffer serious mental illness,” he said.

“This circumstance leads me to recommend that Tasmanian Health Service, in concert with other relevant governmental authorities, co-ordinate a strategy to establish a suitable facility on the North-West Coast which can provide supported accommodation for persons suffering from mental illness and who are unable to care for themselves.”

A Tasmanian Government spokesperson said Mr Chandler’s recommendations would be considered.