Coroner recommendations after inquest into suicide deaths of Mark Furlan and Richard Miller at RAH mental health ward

A coroner has slammed several practices after two men took their own life despite being in the RAH’s mental health ward and under regular observations.

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A coroner has slammed several practices at an Adelaide hospital after two men died by suicide while detained in the mental health ward.

State Coroner David Whittle made several recommendations to help prevent future deaths, including implementing anti-ligature doors and sufficient training to support Department for Correctional Services (DCS) patients.

Two patients, Mark John Furlan, 50, and Richard John Miller, 37, took their own lives while they were under inpatient treatment orders at the Royal Adelaide Hospital.

Each death occurred in Ward 2G, in the mental health ward, about three years apart.

Mr Furlan, a father-of-two, was admitted to the ward after work stress had caused a deterioration of his mental health over a three-month period.

He was suffering psychotic depression and having suicidal ideations.

Mark Furlan died by suicide during a 35-minute period where he was not observed by a nurse. Photo: Supplied

Richard Miller was “acutely psychotic” and expressing suicidal ideations just days before his death. Photo: Supplied

The inquest heard Mr Furlan was supposed to be under 15-minute observations on February 25, 2018.

He was last observed by a nurse at 11.10am that morning and not attended to again until 11.45am when he was found hanging from the ensuite door in his room by his own hooded jumper.

After 24 minutes of resuscitation Mr Furlan began breathing again, however after two days in intensive care, brain death was confirmed.

Counsel assisting Sally Giles told the inquest the ligature point Mr Furlan used, the ensuite door, had been identified months before his death.

Mr Miller was transferred to Ward 2G of the RAH from the Adelaide Remand Centre in June 2021, after a relapse of psychosis.

He was placed on a level 2 inpatient treatment order and was awaiting transfer to James Nash House.

The inquest heard he was “acutely psychotic” and expressing suicidal ideations just days before his death.

Mr Miller was last seen conscious at 10.45am on July 15 at the nursing station before he returned to his room and closed the door.

A nurse reported he looked through the door at 11.02am and saw Mr Miller breathing while lying on his bed facing away from the door.

When the nurse returned to the room sometime between 11.15am and 11.20am, Mr Miller was found unresponsive.

A doctor was called and a ligature was observed around his neck.

Attempts were made to revive Mr Miller, however he was pronounced deceased at 11.55am.

Both men took their own lives while in the Royal Adelaide Hospital’s mental health ward. Picture: NCA NewsWire/Brenton Edwards

In his findings, Mr Whittle acknowledged some changes had already been made since Mr Furlan’s death, including an increase in nursing staff and “continuous observations” required when a patient was considered to be at significant risk to themselves.

Mr Whittle also recommended that the doors in Ward 2G patient rooms should be replaced as a matter of urgency.

“New doors should be anti-ligature and have a viewing window,” he said.

Mr Whittle recommended that all local health networks in South Australia introduce an electronic observation record in all mental health wards for nurses undertaking observations.

“I would recommend that staff are sufficiently trained to support DCS patients,” he further added.

“And that staff have specialist consultation liaison support from the forensic mental health service to the (Psychiatric Intensive Care Unit) PICU who can advise and assist them in their care for DCS patients.”

Originally published as Coroner recommendations after inquest into suicide deaths of Mark Furlan and Richard Miller at RAH mental health ward