“To see a mentally ill person in 2014 at a public hospital in NSW treated in such an appalling manner is really beyond comprehension. The sight of the deceased wandering the corridor naked and covered in excrement while the senior nurse is seen to mop the floor apparently oblivious to her is horrific. While this appears not to be a system failure it is clearly a serious human failure. It is for another place to take such disciplinary proceedings as appear necessary.” [Excerpt from a NSW coronial inquest judgment delivered on 7 September 2016]
The daughter of a woman who died after she was left to wander the halls of a New South Wales hospital while naked and covered in faeces says nurses there lied to her about what happened.
Miriam Merten died in 2014 from a brain injury after she fell over more than 20 times at the Mental Health Unit of Lismore Base Hospital, on the state's north coast.
A coronial inquest heard she was locked in a seclusion room for hours, and when the two nurses supervising her unlocked the door they allowed her to wander around naked, covered in faeces.
She continued to fall over outside the seclusion room.
Coroner Jeff Linden found she died from "traumatic brain injury caused by numerous falls and the self-beating of her head on various surfaces, the latter not done with the intention of taking her life".
"The sight of the deceased wandering the corridor naked and covered in excrement while the senior nurse is seen to mop the floor, apparently oblivious to her is horrific," he said.
The state's chief psychiatrist Murray Wright said he was equally shocked.
"I can't speak for what was happening in the minds of those nurses but I think it's an absolutely appalling incident," he said.
Ms Merten's daughter, Corina Leigh Merten, said she only found out exactly how her mother died when a journalist contacted her recently.
She said that at the time of her mother's death, nurses gave her a different version of how her mother died.
"I was in school, in Year 12, my dad came and picked me up and we went straight to the hospital," she said.
"At the time they told me she slipped and fell in the shower."
Now 20, Corina Merten said she did not know the coronial inquest was on.
"I'm so disappointed that it took a reporter for me to know what actually happened to my mum," she said.
The New South Wales Health Care Complaints Commission said it had found that two nurses caring for a patient who later died from a brain injury kept no record of about 20 falls captured on CCTV.
The woman, known as Patient A, was filmed wandering naked and covered in faeces in Lismore's Adult Mental Health Unit in mid-2014.
CCTV footage showed that in the seven hours before she was transferred to intensive care she fell 24 times.
For most of that time she was alone in a locked room, but nursing records of her confinement made no mention of any falls.
During a five-hour period in the seclusion room, no-one entered to check the patient's temperature, pulse, respiration or blood pressure.
Patient A was not offered any food or water and had no access to a toilet.
The woman died from a brain injury the following day.
The HCCC found the two nurses charged with her care guilty of professional misconduct.
See: Civil and Administrative Tribunal New South Wales, Health Care Complaints Commission v Borthistle [2017] NSWCATOD 56 decision concerning “Patient A” and Health Care Complaints Commission v Burton [2017] NSWCATOD 57 decision concerning “Patient A” .
Each
year complaints relating to mental health make up around 12% of all complaints
received by the Commission.
In
2015-16, there were 759 complaints in this category.
This
means that over the five years from 2011 to 2015-16 the Commission has received
3,051 complaints concerning mental health….
Over
the last five years the Commission received:
807
complaints about medical practitioners;
647
complaints about psychologists;
438
about mental health services in a public hospital and 299 about psychiatric
hospitals;
302
about nurses; and,
220
about community health services.
In addition to the 12% of all health complaints being listed as complaints concerning mental health providers, another 5.4% of all health complaints are complaints concerning psychiatry providers.
This annual
report also stated that 21% of all mental
health complaints between 2011-12 to 2015-16 related to professional conduct
and 31.9% related to treatment.
Of the mental health complaints received in
2015-16 there were:
46 referred
to professional council;
40 resolved
during assessment;
55 referred
for local resolution;
23 investigation
conducted by the HCCC;
46 referred
to the HCCC's Resolution Service;
12 discontinued
with comments;
7 referred to
another body/person; and
226
discontinued with no reasons stated.
Case study included in HCCC Annual Report
2015-16 at page 58:
The
Commission investigated a complaint against a mental health inpatient unit in a
regional public hospital. The key facts were that:
*
Patient A was scheduled under the Mental Health Act 2007 (NSW) with a dual
diagnosis of schizophrenia and alcohol abuse
*
The patient was difficult to manage due to lack of insight, non-compliance with
medication and high level aggression.
*
The decision to co-locate the patient in a double room with Patient B – both unpredictable
and potentially violent patients – without any a risk assessment.
*
On a night shift, required observations either not carried out at all or were
not carried out in the manner required, but staff signed off that all care
level checks were completed
*
Overnight Patient B was killed by Patient A.
The
investigation found that care and treatment of Patient A was inadequate. His
care plan was ineffective, rigid and failed to improve his condition. There
were lost opportunities in terms of appropriate, alternative ways to manage and
treat him. Furthermore, his safety and that of others was put at risk through
the decision to co-locate him with patient B and because staff failed to carry
out the required observations.
A
Mental Health Council of Australia study (2011) found that people with mental
illness reported similar levels of stigma from health professionals as from the
general community.
Some
of the study’s key findings are that:
* Almost 29% reported that a health professional had ‘shunned’ them. These
figures rose to over 50% for people with post-traumatic stress disorder and
borderline personality disorder.
* Over 34% had been advised by a health professional to lower their expectations
for accomplishment in life.
* Over 44% agreed that health professionals treating them for a physical disorder
behaved differently when they discovered their history of a mental illness.
NSW Health Care Complaints Commission decisions recorded in 2016 & 2017 re other nursing staff complaints relating to treatment of patients with a psychiatric illness:
I'm sure NSW residents would all like to believe that each and every time they present at a public hospital they will be treated with professional care and respect.
Unfortunately that is not always the case as prejudice, discrimination and racism are rarely acknowleged by government as existing within the state health care system and are therefore tolerated by default.
“Stigma against
people who have experienced a mental illness is deeply entrenched in our
culture. It finds expression everywhere from the Parliament to the front bar.
From courtrooms and pulpits to playgrounds it is possible to hear people who
experience mental illness cast in an unfair light.” [National Survey of Mental Health and Wellbeing Bulletin 6, Carr
& Halpirin 2002, Stigma and
discrimination]
