Coroner’s report into 20-year-old’s death calls for new mental health unit in Kalgoorlie

A Western Australian coroner has recommended a new mental health unit be built “as soon as possible” in Kalgoorlie after finding a multitude of flaws in the existing facility.

An inquest into the death of Jordan James Williams found a lack of staff, beds, facilities and safe infrastructure at the mental health unit at the Kalgoorlie Health Campus.

Coroner Michael Jenkin also urged the WA Country Health Service to speed up plans for a new purpose-built facility and to take immediate steps to secure fencing around the existing unit.

There are open sections of fences in the unit and two patients have died on a nearby rail line.

Kalgoorlie Hospital is the training ground for many Western Australian doctors.
There were only six beds in the mental health unit at the Kalgoorlie Health Campus. (ABC Goldfields-Esperance: Nathan Morris)

The 20-year-old, whose “smile lit up the whole room”, had battled psychosis and depression after losing his mother in 2016 and his father in early 2018.

In August 2018, he was admitted to the Kalgoorlie Health Campus due to concerns for his well-being.

Chaotic events before death.

Initially, Mr. Williams was treated in the operating room, due to a lack of staff and beds in the mental health unit.

An investigation by the Mental Health Advocacy Service at Kalgoorlie Hospital found that 80 per cent of mental health admissions to the hospital were seen on wards other than the mental health unit due to a lack of beds.

Research by the Mental Health Advocacy Service also found that security guards were used in 95 percent of cases where individual mental health nursing care was needed.

While in the unit, Jordan Williams made multiple attempts to escape and hurt himself.

During one attempt, he was found on the railway, but this information was not passed on to the nurses or his psychiatrist.

The coroner said there was a lack of communication between workers in the unit, which was facing a severe staffing shortage at the time.

Jenkin said that Williams should not have been allowed to leave his room after his first escape.

An aerial image overlooking a gold mine and the town of Kalgoorlie-Boulder captured by a drone.
Kalgoorlie-Boulder, in the West Australian Goldfields, is home to nearly 30,000 people. (ABC News: Tom Edwards )

Mr. Williams was allowed access to the yard again, and he and the security guard assigned to watch him began kicking a soccer ball around with other patients.

After kicking the ball to the guard, Mr. Williams scaled the fence and escaped again.

Around 7:40 p.m. that night, he was found dead after a search.

Existing unit with few resources

The coroner heard that the resources and facilities in the Mental Health Unit were so poor that previous substitute staff had refused to return.

“Dr. Adam Brett said that some of his colleagues who had held substitute psychiatrist positions in [Kalgoorlie Health Campus] I had sworn never to return because the conditions were so bad,” the report says.

Nurse Karly Retimana Te Whatu said she would not want her family members to be treated there.

the exterior of a hospital building.
Jordan Williams escaped from Kalgoorlie Hospital mental health unit and was found dead after a search.(ABC Goldfields: Medina Jaffari)

The coroner said that while he was satisfied the level of treatment and care provided to Mr Williams was appropriate, the level of supervision he received was “demonstrably suboptimal”.

He called on the WA Country Health Service to expedite proposals for a new facility and undertake planning so that when it does open it will be adequately staffed.

The health service accepts all the findings

The WA Country Health Service issued a statement to the ABC in response to the report.

A man in glasses and a suit standing behind a microphone.
WA Country Health Service Goldfields Regional Director Peter Tredinnick says all the coroner’s recommendations have been taken into account. (ABC Goldfields: Jarrod Lucas)

Tedinnick said the unit is not currently facing a staffing shortage.

“The safety of our staff and patients is our highest priority and I can confirm that the facility is adequately staffed to care for patients in the six-bed unit, with one-on-one nursing specialists and additional security options available.” when necessary,” he said. saying.

Leave a Comment