Coroner says Canberra Hospital ‘failed’ four patients who took their own lives

Albert McKnight 5 March 2021
Heidi Ruhl and Melanie Fisher

Heidi Ruhl and Melanie Fisher speak outside the ACT Magistrates Court about the findings into four deaths at Canberra Hospital. Photo: Albert McKnight.

Warning: this article discusses suicide. If you or anyone you know needs help, you can also contact Lifeline on 13 11 14 for 24-hour crisis support.

The Canberra Hospital failed four patients who had been admitted into the care of the hospital’s adult mental health unit and took their own lives in 2015 and 2016, ACT Coroner Margaret Hunter said today.

Coroner Hunter was blunt in her assessment of the circumstances surrounding their deaths, saying all four patients required appropriate observations and all died in the care of the hospital.

She said they all died in a relatively short period of time and “the hospital failed those four patients and their families”.


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Contributing factors included difficulties with staffing, insufficient ongoing staff education and insufficient attention to protocols, practice and procedures.

She also said the court had heard it was not unusual for nursing staff to work double shifts, which happened at the time of the deaths.

“Whilst it is accepted that standards have risen since these unfortunate deaths, the [adult mental health unit] and the hospital were not performing to the standard required,” she said in her findings.

Coroner Hunter acknowledged the grief endured by the four patients’ families and their “frustration and pain”, saying it was clear the deaths had left a profound impact on them.

Nicola Fisher

Nicola Fisher was one of four patients whose death at TCH was investigated by the ACT Coroner. Photo: Supplied.

Families expect their loved ones to be safe when they are admitted to treatment facilities, she said.

She also apologised for the length of time the inquest had taken as the families had been waiting for five or six years for the result.

Coroner Hunter hoped it would be of some comfort to the families that there was a “lasting legacy” from the deaths because as a result of the tragedies, improvements had been made at the hospital, and no more lives had been lost.


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She said the “significant changes” to the short stay and mental health units at Canberra Hospital since the deaths included updated training for nursing staff.

In her findings, she also said there had been changes to staffing levels and better handover procedures.

“I have no doubt the staff at Canberra Hospital work very hard to ensure the safety of their patients,” she said.

Speaking outside the courthouse after the findings were released, Melanie Fisher, the sister of Nicola Fisher, who was one of those who died at the hospital, said there was not enough investment from the federal government towards the mental health sector.

“When people are admitted to the mental health unit in crisis, you have faith and hope that they will be cared for and looked after,” Ms Fisher said.

“As the coroner said, the hospital did fail us in this and it failed the families of the other people who took their lives.

“This is very disappointing, but we don’t really blame the hospital.

“The resourcing for mental health support in Australia and all of the other supports needed is wildly inadequate.

“This is the cause, the real cause, of why we are here today.”

ACT Minister for Mental Health Emma Davidson responded to the inquest’s findings, saying the government had not waited for the coroner’s report to be released before it started working on improvements at the hospital.

“We’re talking about people’s lives here, so obviously, you always want to be doing everything that you can as early as you can,” she said.

“I am glad Canberra Health Services have made quite a lot of changes to the facilities, but we will continue to do more.”

She said a lot of work had been done to minimise ligature risks, electronic monitoring systems had been installed to allow greater observance of people, and a fast review process to quickly identify improvements if an incident did occur had been initiated.

However, she did not directly answer questions over why it had taken four deaths before improvements were made at the hospital.

Coroner Hunter made seven recommendations from the inquest, including that there be a review of the policy relating to dangerous items brought in by patients and that training for the “at-risk observation” policy be reviewed to ensure staff understand its importance.


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