Coroner's Court of Western Australia

Inquest into the Death of Russell David BROCKLISS

Inquest into the Death of Russell David BROCKLISS

Delivered on : 22 October 2021

Delivered at : Perth

Finding of : Deputy State Coroner Linton

Recommendations : Yes

I recommend that the Honourable Roger Cook MLA, Deputy Premier and Minister for Health, give urgent consideration to funding a redevelopment of the Broome Hospital Mabu Liyan High Dependency Unit in order to ensure that two patients can be safely, and sensitively, housed and cared for in the HDU at all times, with the ability for the staff to be co-located in a secure area within that unit in order to facilitate regular visual observations, and furnished in such a way that the area is safe for patients and staff but patients are still able to be accessed for appropriate resuscitation in the event of a medical emergency.

Orders/Rules : N/A

Suppression Order : N/A

Summary : Mr Brockliss was an Aboriginal man from the Broome region who had developed a severe and longstanding mental illness precipitated by illicit drug use. His most recent diagnosis was schizoaffective disorder. Mr Brockliss had supportive parents and was connected with mental health services, but had regular periods of deterioration where he required admission to hospital for involuntary mental health treatment. As well as his mental health, Mr Brockliss was deemed to be at high cardiovascular/metabolic risk, but he refused examination, investigations and treatment.

At the time of Mr Brockliss’ death, he was an involuntary patient and was being treated in the High Dependency Unit at Broome Regional Hospital. He had been taken to the Broome Hospital ED by police in the early hours of the morning on 7 June 2019, after his mother requested assistance in relation to him having a mental health episode. He was highly agitated in the ED at the time of his admission and had to be sedated. Only a limited physical examination and limited physical observations were performed due to his agitated state. Mr Brockliss was referred to the psychiatric unit, Mabu Liyan, on forms. Mr Brockliss was then admitted to the High Dependency Unit and administered further sedation on the ward. No further physical observations were taken during the day as Mr Brockliss initially refused to be assessed. At the time of the change to night shift, Mr Brockliss had calmed somewhat, but it does not appear any further attempt was made to take his physical observations at that time. There was a plan to take his observations the next morning.

As a patient in the High Dependency Unit, Mr Brockliss was supposed to be visually observed by a staff member every 15 minutes. There is a record that shows he was checked almost every 15 minutes up until midnight. The chart for the checks from midnight was missing at the time of the inquest, but it was assumed that the checks continued overnight. Evidence was given that some of the checks were completed by a nurse looking through a small window and observing Mr Brockliss in bed and monitoring his breathing, rather than entering the HDU, as nurses had to go in pairs into the HDU for safety reasons. This practice has now changed, but was not uncommon at the time of Mr Brockliss’ death. The nurse who was doing the checks in the morning had last checked Mr Brockliss at 8.15 am through the window and she believed he was breathing and had recently moved position at that time, although she conceded at the inquest that she may have been mistaken.

Mr Brockliss was found unresponsive in his bed the following morning just after 8.30 am on 8 June 2019 when two nurses entered the HDU to wake Mr Brockliss up in preparation for observations and blood samples to be taken. The Medical Emergency Team attended but resuscitation attempts were unsuccessful. A GP Anaesthetist who took the lead in the resuscitation formed the view that Mr Brockliss had been deceased for a longer period of time than first thought. Based upon the information available to him, the GP Anaesthetist believed Mr Brockliss was probably already deceased by about 7.00 am.

The Deputy State Coroner noted that while a missed opportunity to try to take some additional physical observations from Mr Brockliss on the night before his death, the Deputy State Coroner was satisfied that it was not clear whether it would have made any difference to the final event, as Mr Brockliss may not have cooperated and/or he may still have suffered a sudden medical event without warning later. The Deputy State Coroner observed that there was evidence that supported the conclusion that the visual observations being performed on Mr Brockliss on the night he died were inadequate, but again it was unclear whether it would have made any difference to the final outcome.

The Deputy State Coroner noted that WACHS had acknowledged that lessons must be learnt from Mr Brockliss’ death and a number of changes had been made to relevant policies, including active consideration of a treatment plan by a psychiatrist where a patient has refused physical observations, and a new requirement for two nurses to always enter the HDU to check any sleeping patient and record their respirations.

The Deputy State Coroner made a recommendation in relation to the redevelopment of the HDU. which was supported by WACHS.

Catch Words : Involuntary Patient : Physical Observations of Mental Health Patients : Managing Patients in High Dependency Units : Natural Causes

Last updated: 15-Nov-2021

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