18 Jun 2009

Hospital procedures improved, inquest into patient death told

5:35 pm on 18 June 2009

An inquest into the death of a man at Christchurch Hospital last year has been told that the emergency department has since changed the way it assesses psychiatric patients.

Trevor James McAlister, 41, went to the hospital requiring psychiatric assessment after making an attempt on his own life.

In line with standard procedure at the time he was made to wait to see a medical doctor before the psychiatric assessment.

He'd been assessed in ED as level 3, meaning he needed to be seen medically within 30 minutes. After 17 minutes he was taken to an ED cubicle but he went missing a minute later, and was subsequently found dead in an emergency room.

Nursing training to be more intensive too

The department's clinical director, Dr Angela Pitchford, told the coroner on Thursday that a review group had since been set up to improve the care of patients with mental health problems. Improvements included giving staff better access to psychiatric patient notes and one-to-one observation of patients who self-harm.

A member of Mr McAlister's family asked whether nursing staff could also be given better training to improve their awareness of suicide risk; Dr Pitchford said ongoing nursing training would be more intensive than it was in the past.

Nurse had no formal psychiatric training

Earlier, the inquest heard that the nurse who assessed Mr McAlister in ED had no formal training in psychiatric care and relied on her own experience to assess whether he was at risk of harming himself.

Vera Fortune, a registered nurse, said she left Mr McAlister alone for only a minute or two.

A DVD of security footage from within the department showed a clearly agitated Mr McAlister rocking and swaying as he was being assessed.

Canterbury District Health Board has made a public apology to the family, saying his death was sincerely regretted.

The coroner reserved his decision.