Inquest into the Death of Phillip Benjamin VELTMAN

Inquest into the Death of Phillip Benjamin VELTMAN

Delivered on :19 July 2024

Delivered at : Perth

Finding of : Coroner Urquhart

Recommendations :Yes

In order to provide an improved standard of physical care for mental health patients, that funding sought for the Community and Virtual Care’s “Sensibles” project be provided by the Future Health Research and Innovation Fund with the Department of Health, so that technology that enables patient observations to be taken remotely can be developed and made available through a secure and confidential system.

Orders/Rules : N/A

Suppression Order : N/A

Summary : On 16 July 2020, Philip Benjamin Veltman (Mr Veltman) died from an unascertained cause in a locked ward at Bentley Mental Health Services (BMHS) situated in Bentley Health Services (BHS). He was 49 years old. At the time of his death, Mr Veltman was an involuntary patient under the provisions of the Mental Health Act 2014 (WA) and an inquest into his death was mandatory as he was a person held in care.

Mr Veltman was diagnosed with schizoaffective disorder that was treatment-resistant. From August 2016,  he spent more than three of the four years before his death in hospital mental health wards. In addition, Mr Veltman also had significant physical health comorbidities which included congestive heart failure, obstructive sleep apnoea, type-2 diabetes and obesity. 

On 7 July 2020, Mr Veltman was discharged from BMHS on a Community Treatment Order after an eight-week admission. However, on 15 July 2020, he was taken to the ED at Royal Perth Hospital (RPH) by police after he was reported to be acting in an erratic manner at a supermarket.

At the ED, Mr Veltman continued to behave in an agitated and unpredictable manner. He was assessed as having an acute manic psychosis and the decision was made to transfer him to BHMS as an involuntary patient. Given his aggressive behaviour in the ED, Mr Veltman was given regular boluses of ketamine and an injection of Acuphase (an antipsychotic medication) just before 10.00 am. At about 5.40 pm, Mr Veltman was transferred to BMHS. He was still highly aroused and refused to be physically assessed by the admissions doctor from BHS.

Significantly, an up-to-date medication chart from RPH was not part of the documents that the admission doctor reviewed. The Acuphase injection was not recorded on the RPH medication chart that the admissions doctor examined. Consequently, the protocols for the monitoring of patients who have had Acuphase administered were not followed at BMHS.  

Throughout the morning of 16 July 2020 Mr Veltman was allowed to remain asleep, and he was not wakened for physical observations by nursing staff. A decision was also made to postpone the doctor’s review until 1.40 pm to allow Mr Veltman further sleep. When staff entered Mr Veltman’s room to perform that review he was found unconscious and not breathing. Despite prompt resuscitation efforts by medical staff, Mr Veltman could not be revived and a doctor certified he had died just before 2.00 pm.

Although the forensic pathologist who performed the post mortem examination was unable to ascertain the cause of death, the other observations made by the forensic pathologist enabled the Coroner to conclude that Mr Veltman’s death was a consequence of a cardiac arrhythmia with terminal aspiration. 

The Coroner was satisfied that the supervision, treatment and care Mr Veltman had received at the ED of RPH was of a high standard.  As to the supervision, treatment and care provided to Mr Veltman at BHS, the Coroner found there was a significant oversight by the admission doctor in not identifying Mr Veltman had been given an injection of Acuphase at RPH. Although there was no up-to-date medication chart, there was another document from RPH that was in possession of BHS at the time of Mr Veltman’s admission to BHMS which indicated Acuphase had been given to him.

The Coroner was satisfied of the changes and improvements that have been implemented by the East Metropolitan Health Service (EMHS) since Mr Veltman’s death. These should lead to a higher standard of monitoring and care for mental health patients; particularly those who have been given sedating medications in hospital.

The Coroner made one recommendation that should assist the efforts of EMHS to introduce significant improvements in the care of mental health patients who are non-compliant with the taking of physical observations. 

Catch Words : Involuntary Patient : Person Held in Care : Recordkeeping : Natural Causes

Last updated: 19-Aug-2024

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