Coroner's Court of Western Australia

Inquest into the Death of Petya Evgenieva PETROVA-CIZEK

Inquest into the Death of Petya Evgenieva PETROVA-CIZEK

Delivered on : 7 March 2024

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations :Yes

Recommendation No. 1

As a matter of the utmost urgency East Metropolitan Health Service should ensure that sufficient funding is made available so that remediation work to address all low, medium, and high ligature risks in its mental health facilities (identified during internal and external audits) is completed as promptly as possible.

Recommendation No. 2

East Metropolitan Health Service should take immediate steps to ensure that at all of its mental health facilities, clinicians assessing patients for possible admission have (at the time of that assessment) access to that patient’s Mental Health Triage documentation, and any relevant outpatient notes, whether in hard copy or by way of an electronic medical record system.

Recommendation No. 3

East Metropolitan Health Service should review the current system of allocating two patients to each nurse working on Ward 6 at Bentley Hospital.  The review should consider whether the current allocation is appropriate in all circumstances, and whether the available mechanisms to assess patient acuity are properly able to ensure that in each case, the nurse to patient allocations are correct.

Orders/Rules : No

Suppression Order : N/A

Summary : Ms Petya Evgenieva Petrova-Cizek (Petya) was 41-years of age when she died on 16 December 2020 at Bentley Health Service (BHS) from ligature compression of the neck.  At the relevant time, Petya was the subject of an inpatient treatment order made under the Mental Health Act 2014 (WA), and was thereby an “involuntary patient” and a “person held in care”.

Petya’s mental health declined after her husband sustained a workplace injury in early March 2020.  Petya became “withdrawn and downcast” and was “suspicious of everyone”, and that in October 2020, her husband took her to see her GP.  Petya complained of severe insomnia, headaches, memory lapses, and poor functioning at work.  Although she had some time off work and took prescribed medication, Petya’s mental health did not improve and following a home visit by clinicians from BHS’s Adult Mental Health Trauma Team, during which Petya expressed suicidal ideation and paranoid thoughts, she was admitted to BHS on 9 December 2020 for further assessment.

Following an assessment by a consultant psychiatrist on 10 December 2020, Petya was made the subject of an inpatient treatment order under the MHA and she was admitted to Ward 6, a locked ward at BHS.  During her admission, Petya’s paranoia and suspiciousness persisted.  She spent most of her time in her room and generally declined to engage with clinical staff.

During her admission, the consultant psychiatrist for Ward 6 was on annual leave.  Although another consultant psychiatrist was providing leave cover, they were unable to spend much time on Ward 6 because they were also required to manage their own substantive full-time role.  As a result, there is no evidence that Petya was reviewed by a consultant psychiatrist after being placed on an inpatient treatment order.

During her admission, Petya’s husband visited twice daily and brought in meals.  Although some concerns had been raised about his interactions with his wife, these concerns were never substantiated before Petya’s death.

On 15 December 2020, Petya’s case was discussed at a multidisciplinary meeting, and despite there having been no significant change in her mental state, Petya’s risk of self-harm was reduced to “low”.  During lunch that day, Petya was involved in a verbal and physical altercation with another patient, and she was reviewed by psychiatric registrar.  Petya was described as “more settled” following the review, but she later spoke with her mental health advocate, and said words to the effect that she “would be better off dead”.  According to the advocate, Petya also said she had a plan to take her life, and although the advocate recalls passing this information on to Petya’s nurse, the nurse is adamant she was not told about Petya having a plan.  In any case, the nurse went to speak with Petya who said she was fine and seemed dismissive of enquiries about her mental state.

On the morning of 16 December 2020, Petya’s husband brought in some breakfast and says he noticed a prominent mark on Petya’s neck which she claimed was “from a strap”.  Although he raised this matter with nursing staff, there is no evidence of what (if anything) was done about these concerns at the time.

Shortly after 5.00 pm on 16 December 2020, a nurse conducted a routine observations of patients on the ward, found Petya hanging in her room.  She was unresponsive, there was a ligature around her neck made of shoelaces (which had not been removed on her admission to Ward 6).  Despite resuscitation efforts by clinical staff, Petya could not be revived.

After carefully considering the evidence, the coroner concluded that the supervision, treatment and care provided to Petya whilst she was an involuntary patient at BHS was inadequate.  The coroner also identified a number of missed opportunities where, with the benefit of hindsight, Petya should have been provided with an enhanced level of care.

The coroner made three recommendations aimed at enhancing the treatment provided to mental health consumers at BHS.

Catch Words : Involuntary patient : Persistent paranoia : Insufficient medical reviews : Ligature minimisation : Suicide

Last updated: 5-Apr-2024

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