INQUIRY INTO CONDITIONS AT KALGOORLIE HOSPITAL …

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INQUIRY INTO CONDITIONS AT KALGOORLIE HOSPITAL WHICH ARE LIKELY TO ADVERSELY IMPACT ON THE HEALTH, SAFETY OR

WELFARE OF MENTAL HEALTH PATIENTS

November 2018

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TABLE OF CONTENTS Issues giving rise to Inquiry .................................................................................... 4 Investigations conducted by the Senior Advocate as part of the Inquiry ........... 5 Mental health patient data ....................................................................................... 5 Conditions at Kalgoorlie Hospital for mental health patients .............................. 6

A ward (adult mental health unit)......................................................................... 6

B ward (medical ward) ........................................................................................ 9

High dependency unit and emergency department ............................................. 9

Surrounding environment .................................................................................. 11

Staffing .................................................................................................................... 13

Ward staffing ..................................................................................................... 13

Medical staffing ................................................................................................. 14

Use of security guards ...................................................................................... 15

Transfers to Perth .................................................................................................. 16

Mental health patient flow ................................................................................. 16

Kalgoorlie Hospital transfer practice and procedure .......................................... 16

Royal Flying Doctor Service practice and procedure ........................................ 17

Alternatives to RFDS ......................................................................................... 18

Sedation of mental health patients .................................................................... 18

Step up step down facility ................................................................................. 19

Broome mental health unit ................................................................................ 19

Conclusions and suggestions for redress ........................................................... 20 Recommendations ................................................................................................. 22 Recommendations relating to Kalgoorlie Hospital ward and staffing conditions ................................................................................................. 22

Recommendation 1: .......................................................................................... 22

Recommendation 2: .......................................................................................... 22

Recommendation 3: .......................................................................................... 23

Recommendation 4: .......................................................................................... 23

Recommendation 5: .......................................................................................... 23

Recommendation 6: .......................................................................................... 23

Recommendations relating to timely and safe access to treatment .................................................................................................................... 24

Recommendation 7: .......................................................................................... 24

Recommendation 8: .......................................................................................... 24

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Recommendation 9: .......................................................................................... 24

Recommendation 10: ........................................................................................ 25

Recommendation 11: ........................................................................................ 25

Annexure 1: WACHS Assertive Patient Flow and Bed Demand for Adult Services: Policy and Practice Guidelines ............................................................ 26 Annexure 2: WACHS Link Unplanned Adult Inter-hospital Patient Transfer Model ....................................................................................................................... 29

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Issues giving rise to Inquiry 1. This Inquiry arises from two incidents involving young people in Kalgoorlie hospital, but MHAS

has been concerned about delays in access to specialist adolescent inpatient services for children (under 18 years) and young people in regional areas for some time. MHAS also has concerns about the safety of patients at Kalgoorlie Hospital who require transfer to another hospital during times of acute risk. The concern for both groups includes their safety in the hospital while waiting for transport and bed admission, and the delays that often occur during this process.

2. In November 2017 MHAS conducted an Inquiry and wrote to the Western Australian Country Health Service (WACHS) regarding two children being cared for in a regional emergency department (ED) and an adult mental health ward:

2.1. In October 2017 a child presented to Derby ED. They absconded and were brought back by police expressing suicidal ideation. Ketamine was used as sedation and they were transferred to Fiona Stanley Hospital (FSH) via Royal Flying Doctor Services (RFDS) three days after they first presented to ED.

2.2. In October 2017 a child absconded from Kalgoorlie Hospital ED. They were brought back and placed in the High Dependency Unit (HDU) where they also absconded from. They were then brought back through ED, HDU and eventually admitted to the adult mental health ward (A ward). They were treated with a ketamine infusion and transferred to Bentley Adolescent Unit (BAU) four days after they first presented to ED. They were discharged the next day and flown back to Kalgoorlie where they presented back to ED only a few days later. They were then quickly transferred back to BAU.

3. Earlier in the year MHAS became aware of the following situations involving children and young people in regional hospitals:

3.1. In July 2018 a child in Broome Hospital had a delayed transfer to East Metro Youth Unit (EMYU) due to RFDS prioritisation of patients. EMYU had the bed open for two days before they could be transferred. They waited for the flight on an adult mental health unit.

3.2. In July 2018 a young person with an intellectual disability was sedated with ketamine on and off for six days in Kalgoorlie Hospital. They initially absconded and were brought back by police. Following this they were placed in HDU. As the sedation wore off the young person assaulted staff and was intubated. They were eventually transferred to FSH ED via RFDS.

4. In August 2018 a young person on A Ward of Kalgoorlie Hospital absconded over the fence in the outdoor area with a security guard in situ. Tragically, they were hit by a train on nearby train tracks and died.

5. In September 2018 a child was brought in to the ED of Kalgoorlie Hospital following family members becoming very concerned for their welfare. The child was friends with the young person described above who died and was said to be significantly impacted by this. A decision was made that specialist adolescent inpatient services were needed and referrals were made to FSH youth unit and EMYU:

5.1. The child waited on the adult medical ward of Kalgoorlie Hospital (B ward) with a security guard in situ. They waited four days for a bed to be confirmed at EYMU. This

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was in part due to current patient cohort and high acuity on EMYU and a decision was apparently made to postpone all admissions on this basis, though beds were available.

5.2. It was reported by family that while waiting for a bed to be secured, the child made four attempts to abscond from hospital, attempted to keep possession of a cutlery knife for purposes of self-harm and attempted to use television cords in their room as a ligature.

5.3. Once a bed was available and confirmed from EMYU, RFDS was secured but the flight was then cancelled twice due to other patients being deemed as being a higher priority.

5.4. While waiting for confirmation of a RFDS transfer six days after initially being brought to ED by police, the child absconded from B ward and jumped from a nearby bridge that crosses the train tracks. They suffered extensive injuries and were flown to the Trauma Unit of Royal Perth Hospital by RFDS as a category 1 transfer.

Investigations conducted by the Senior Advocate as part of the Inquiry 6. For the purposes of the Inquiry Senior Advocate, Victoria Gwilliams, attended Kalgoorlie

Hospital on Friday 14 September 2018. She also spoke with senior mental health nursing staff, mental health nursing staff, allied health staff, a locum psychiatrist and senior general nursing staff at Kalgoorlie Hospital, mental health advocates and patients. She also met with the Goldfields Regional Director and the Regional Manager, Mental Health, from WACHS. Follow up conversations were held with senior nursing staff and the Regional Manager.

7. She also spoke with the Nurse Director of Mental Health Patient Flow, the EMYU Nurse Unit Manager, WACHS Executive Director for Mental Health and the family of one of the young people whose situation is outlined above.

8. Broome Hospital was also visited on 27 September 2018 by the Senior Advocate which was useful for comparison and overview purposes. In that visit the Senior Advocate spoke with senior mental health nursing staff, mental health nursing staff, allied health staff, advocates and patients as well as the Kimberley Acting Regional Director from WACHS.

9. The facts, findings and recommendations below are based on information provided in these interviews and subsequently, as well as MHAS data and information.

Mental health patient data 10. Since January 2016 the number of involuntary patients in Kalgoorlie Hospital notified to MHAS

(forms 6A and 6B, the latter for patients on a general ward) has increased and continues to increase:

• January – June 2016 = 23 • July – Dec 2016 = 21 • January – June 2017 = 17 • July – Dec 2017 = 21 • January – June 2018 = 28 • July to Oct 2018 = 26 in four months

The number of involuntary orders made in Kalgoorlie Hospital in the four months from July to October this year (as notified to MHAS) increased by 44.4% over the same period for 2016-17

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(from 18 to 26 including three form 6B orders). Overall the number of involuntary orders in WACHS hospitals across the state has increased by 11.5% for the period July to October when compared with the previous year. The increase is not only in Kalgoorlie.

11. The number of involuntary youth (aged 18 to 24 years) in Kalgoorlie has also increased particularly this year. In the two years, 2016 and 2017 there were 15 young people made involuntary in comparison to 20 young people made involuntary in the past 10 months.

12. The MHAS data does not include voluntary children (aged under 18), voluntary adult patients or people in the ED.

13. Kalgoorlie Hospital advised that there are approximately 270 mental health admissions per year to Kalgoorlie Hospital and that approximately 30% of mental health patients (or more than 80 people) were “outliers” at some point in their admission. Outliers are patients treated in other wards of Kalgoorlie Hospital because of the lack of bed availability on A ward.

14. According to hospital staff the outlier numbers are variable, but on average every day there is at least one outlier patient. A few weeks prior to the Senior Advocate’s visit a “code yellow” was called as there were approximately six mental health outlier patients in the hospital.

15. The WA Mental Health and Alcohol and Other Drug Services Plan 2015-2025 (the Mental Health Plan) refers to modelling done in 2015 and states at page 117: “Mental health inpatient beds and HITH beds are required to grow to 20 beds and five beds, respectively, by the end of 2025.”

Conditions at Kalgoorlie Hospital for mental health patients 16. Mental Health patients in Kalgoorlie Hospital may be cared for in the ED, HDU, A ward and B

ward.

A ward (adult mental health unit) 17. The entrance to the authorised 6 bed mental health ward at Kalgoorlie Hospital is via

automatic sliding doors operated by a swipe card. There is a second set of doors further inside leading to the ward but it is not a secure airlock.

18. On the Senior Advocate’s visit the doors leading into the ward had a sign stating that patients were at risk of absconding and nobody should enter without being allowed access from a staff member. Ward staff said the sign was put up many months ago and aimed at general staff who were not vigilant when entering the ward despite constant reminders. This was put down to a potential lack of understanding about the vulnerability of mental health patients and the risk of absconding.

19. When let onto the ward by staff or via swipe card, the automatic doors opened and shut quickly and didn’t allow a great deal of time for people to pass through. WACHS staff said that this was a deliberate measure put in place following patients absconding from the ward.

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20. A ward appeared to be clean and smelt pleasant on that day; there were six soft and comfortable chairs in the small living area, as well as a large massage chair available for patient use. See picture 1.

Picture 1. – Lounge area on A Ward.

21. The small kitchen/dining area had facilities for patients to make their own meals though apparently this does not happen very often. See picture 2.

Picture 2 – Kitchen and dining area on A Ward.

22. There was a quiet room that doubled as an activities room. A patient was in the quiet room with a security guard so the access to an activity room was limited on the day of the visit.

23. The courtyard was well maintained with plants and flowers as well as a seated area and a smoking shelter. See picture 3. The surrounding fence had a tubular feature along the top to act as a deterrent to people climbing over the fence to the general hospital grounds. See picture 4. From here it is easy to navigate your way out of the hospital.

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Picture 3 - The right hand side of the courtyard when looking out from the ward. The smoking shelter can be seen directly ahead and flower beds to the right

Picture 4. Close up of the fence and the tubular feature that runs along the top, near to the area that was jumped over by the young person who absconded from the ward and died.

24. Senior nursing staff said that young people in particular could easily and quickly get over the fence. The young person who was recently hit by a train had absconded while playing football with a security guard in the garden which had happened very quickly when the guard turned his back to get the ball. The patient got over the left hand corner of the fence (when looking at it from the ward) but staff said the most common area to climb over was directly to the right of the smoking shelter.

25. Since visiting the Kalgoorlie Hospital MHAS are aware that another patient has managed to abscond over the fence on A ward despite having a security guard present. They were brought back with injuries and two security guards were provided to the outdoor area in an attempt to further reduce this risk. They were then transferred to the ED of FSH following a two day wait for a RFDS flight. At this time the height of the fence was raised as a temporary measure however this is not ideal and it is now a risk if someone attempts to climb the fence and falls from the top.

26. WACHS staff have travelled to Perth to investigate options for making the fence at Kalgoorlie Hospital safer and that the option of a mesh conservatory style roof which would be connected to the fence was being explored. It was felt that this would provide safety in a way that would not intrude on the currently comfortable and pleasant ward environment.

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27. Patients cannot be secluded or restrained on the ward due to staffing levels and the seclusion room is used as a storage room. Nursing staff said that they would always want to avoid seclusion but that on occasion it would be useful when managing extreme risk.

28. Staff advised that if medication had to be administered forcibly they had to source a bed on HDU and escort the patient there. This was due to low staff numbers on A ward. On occasion police have needed to be called to A ward to assist with restraints and that this can take time to coordinate, though this was rare.

29. WACHS believe that with increased workforce and extra training it may be possible to have the opportunity to provide restraint to patients on A ward in the future, though this would only be used when necessary.

30. The ward was full on the day that the Senior Advocate visited with two outliers located on the other wards. One of the voluntary patients on A ward said that he was treated well and that the ward was always clean. He said that the ward offered him a quiet space to relax and he had been using it on and off for eleven years in navigating his mental illness.

31. There were a few very unwell people on the ward that day and the Senior Advocate was asked not to disturb them. The ward appeared settled and quiet each time she was there between 8:50am and approximately 3:30pm.

32. Concern was raised by staff that that over time equipment such as a basketball hoop and a radio has been removed from the ward due to safety risks, and this this has resulted in reduced opportunity for patients to enjoy ward based activity. An art therapist visits the ward three times a week to facilitate painting and clay modelling and patients apparently engage well with this activity.

B ward (medical ward) 33. B ward is used by mental health patients to create capacity when A ward is full and these

patients are known as outliers. It may be used when mental health patients have additional prominent physical health needs and it has also been used to avoid a child being placed on an adult mental health ward.

34. A single set of electronic sliding doors marked the entrance to B ward but they did not open and close with the speed of the doors on A ward. They were immediately next to another set of automatic doors that led out of the hospital to the car park which was close to train tracks and a bridge. The Senior Advocate was told that they could be locked if it was identified that someone was at risk of absconding from the ward and that they were usually not locked during visiting hours.

35. Staff spoke about the difficulties in managing patients who were experiencing delays in transfer from Kalgoorlie. Staff were first on the scene when a child recently absconded from B ward and jumped off a bridge. The child’s mother and other patients witnessed the incident and the aftermath.

High dependency unit and emergency department 36. The HDU is used by mental health patients when risk and patient need becomes greater than

can be managed on other wards. An example of this is when a restraint is needed to forcibly medicate a patient or when a patient needs a transfer and it is not safe for them to wait on another ward.

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37. HDU is a communal ward with no natural light. One young person was in there for mental health reasons at the time of the Senior Advocate’s visit with a security guard. They were sitting up in bed and the guard was sitting in a chair at the end of the bed looking at a mobile phone. The young person was discharged home later that day.

38. The main doors at the front of the ward were locked but there were two lots of doors at the back of the ward that couldn’t be locked as they were fire doors. These doors led through to ED and once there, certain corridors could be accessed which led to the main ED exit. See Picture 5. Staff said that local patients would know how to navigate their way around easily and quickly. The doors that required a swipe card took a long time to close and some closed one door at a time. Since then we are told that the security of some doors in this area has been increased with a greater number of them now requiring a swipe card to allow entry.

Picture 5. The corridor leading to exit doors of the hospital that can be seen when leaving HDU via fire doors that can’t be locked.

39. The ED has a low stimulation room which is said to be helpful for mental health patients but HDU and ED appeared to be very difficult spaces to safely contain someone when they are acutely unwell. Problems highlighted by staff with managing and caring for mental health patients in HDU were as follows:

39.1. the lack of mental health staff available. Staff said that mental health nurses help in getting oral medications on board quicker and HDU nurses often rely on intravenous (IV) medications; mental health nurses are also more successful in de-escalating situations with mental health patients;

39.2. the lack of access to smoking on the HDU which can increase agitation, especially when patients have been transferred from A ward where smoking can be facilitated;

39.3. invasive monitoring needs on the HDU causing frustration to patients;

39.4. the use of cables and IV medications creating further agitation and restrictions; and.

39.5. general nursing staff feeling that they did not have the expertise required to communicate with families of mental health patients in a way that supported their understanding of the patient’s condition and the need to transfer them away from Kalgoorlie Hospital.

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40. Again, it was evident that staff members were very distressed by some of the situations they have found themselves in while patients have been awaiting transfer from Kalgoorlie Hospital. One senior nurse stated: “The worst part of this job is the feeling you have when these patients run away.” Another staff member expressed that help was urgently needed in these cases: “When we say it is high priority we mean business. We are saying that we can’t cope here.”

Surrounding environment 41. Kalgoorlie Hospital is located next to a railway line and the surrounding fence is damaged in

part which allows direct access to the railway tracks from the hospital. See picture 6. There is also a bridge nearby which crosses the tracks and leads to the town centre. The bridge is known in the local community to be dangerous due to the busy traffic as well as the side rail not being high enough. See pictures 7 and 8.

42. The young person who recently died on these train tracks is the second mental health patient killed in this way, the first being a patient who was killed by a train in 2011 while on ground access leave from A ward.

43. The Senior Advocate was told that an Indigenous Community Centre has relocated due to their premises previously being in close proximity to the bridge and the risk that it posed to vulnerable people. WACHS Goldfields Regional Director advised that following a meeting with the Mayor and Chief Executive Officer of the City of Kalgoorlie-Boulder, a project had been planned and costed to improve the safety of the bridge and fence surrounding the train track. MHAS wrote to the City of Kalgoorlie-Boulder recommending that the project be rolled out.

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Picture 6. The damaged fence surrounding the train tracks.

Picture 7. View of the bridge that crosses the train tracks from the edge of the Kalgoorlie Hospital car park.

Picture 8. The bridge that the child jumped from after absconding from B ward in September 2018.

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Staffing Ward staffing 44. Shifts on A ward are staffed by two mental health nurses and sometimes a student nurse. A

social worker works between A ward and the community mental health service. There is one full time psychiatric liaison nurse (PLN) position across the hospital based in the ED working from 8:00am until 4:30pm Monday to Friday. There is an occupational therapist position that was advertised earlier in the year without any suitable applicants. This is now being readvertised.

45. There are a team of Aboriginal mental health workers based in the community mental health service who provide in reach to the hospital. The Senior Advocate was told that these staff members were an asset to the hospital and had a positive impact on the mental health patient journey.

46. The issue in having only two nurses per shift means the team is not able to cope with anything “out of the ordinary.” An example was a potent strain of methamphetamine in Kalgoorlie which was anticipated to result in a code yellow for Kalgoorlie Hospital mental health beds resulting in pressure for staff and patients. The other risk is staff member “burn out”, especially in light of the trauma experienced during recent events.

47. Various staff members articulated that having two mental health nurses per shift was inadequate and that having more mental health nurses available for mental health patients throughout the hospital would be beneficial because:

47.1. it would mean that mental health nurses could provide specialling arrangements instead of relying on security guards;

47.2. having mental health nurses doing the specialling provides one to one time with patients and a better opportunity to recognise early warning signs of risk and to de-escalate situations;

47.3. it would allow mental health nursing in-reach to the other wards, where outlier patients were being cared for; noting that mental health nurses have a greater understanding of suicidality and are better equipped to identify suicidal intent, as opposed to suicidal ideation. This would lead to a safer risk assessment and care for those patients;

47.4. it would facilitate more ward based activities which might reduce the incidence of people trying to abscond and agitation and distress on the ward thereby increasing safety; and

47.5. it would support staff to manage workload and avoid “burn out”.

48. Concern was also raised by mental health staff that the stigma of mental health may be impacting on the general nurses from other wards resulting in outlier patients being over-medicated in order to control behaviour.

49. A senior staff member did not feel that was the case though they thought some general staff may be afraid of mental health patients due to incidents of aggression and that some general staff may not be confident in understanding the difference between “bad behaviour” and mental illness. It was acknowledged that mental health patients are best served by mental health staff and that nursing mental health patients on the HDU is not ideal.

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50. WACHS commented that a patient’s medication schedule is always managed by the senior medical practitioner (SMP) or a psychiatrist.

Medical staffing 51. Kalgoorlie has not had a permanent medical director of psychiatry since 2014. MHAS was

informed in 2011 that WACHS had approved a fly in/fly out (FIFO) model of service for psychiatrists in Kalgoorlie Hospital following the resignation of a locally based registrar.

52. The mental health medical staff complement includes:

• a locum psychiatrist

• a locum SMP

• a permanent registered medical officer (RMO) in A ward; and

• a locum psychiatrist in the community mental health service.

53. WACHS advised that there are currently about eight regular psychiatrists who provide services to Kalgoorlie on a regular FIFO basis for approximately two to four weeks at a time. During times when these eight are not available, others are used and they usually come for shorter periods.

54. According to staff having a locum FIFO psychiatrist arrangement has a clear and detrimental impact on service delivery, and that some only come for three days at a time. It was not uncommon for each doctor to have differences in clinical opinion and a change of doctor could result in a change of medication, diagnosis or approach for the patient. MHAS has been told this previously by psychiatrists attending at the hospital that it is an issue. This lack of consistency was sometimes viewed as a barrier to patient understanding and something that potentially extended admissions. It must increase the risk of errors, be confusing and frustrating for consumers and carers, difficult for nursing staff taking different instructions, and hamper the preparation of treatment support and discharge plans.

55. Staff also said that the quality of the psychiatrists who visit Kalgoorlie was variable and some lacked a contemporary approach. One psychiatrist had made homophobic comments to staff. This was escalated to WACHS management who resolved the issue but as a staff member said: “this is the rubbish we have to put up with in Kalgoorlie”.

56. An absence of clear and consistent leadership in psychiatry was cited as a problem and something that resulted in a lack of direction and progression as a service: “We are reinventing the wheel every fortnight.”

57. There also appeared to be some confusion around who to contact for psychiatric assistance out of hours with some staff in the hospital commenting that they could only contact a psychiatrist if they left their mobile number. WACHS however, confirmed that there was always a psychiatrist on call and that a process had recently been put in place to make it clear to staff who they should contact. This appears to be indicative of the potential for disconnect that can impact mental health patients on wards other than A ward.

58. Professional isolation was also an issue raised in relation to staff development and morale. Staff said that there is a SMP who comes to work in Kalgoorlie one month at a time and this arrangement works better - there are some high quality locum psychiatrists but “the good ones don’t always come back because they walk into a mess”.

59. The Senior Advocate spoke to the locum psychiatrist there at the time who had arrived a few days earlier. He said he was the psychiatrist for the community mental health service as well

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as the hospital and that he would not have agreed to the work if he knew that he was not going to have junior staff available. He complained that he did not have the support structure of a locum SMP and RMO available to him as outlined by WACHS. Apparently this was due to absences that week due to various unavoidable circumstances.

60. The locum psychiatrist said that the way to get a permanent psychiatrist to Kalgoorlie was undoubtedly to provide greater financial incentive in order to compensate for the social and family sacrifices that would need to be made. He explained that the clinical lead role was currently advertised at a standard salary level which did not provide any financial incentive. He added that the locum salary is not competitive and that he could earn $500 a day more as a locum in other areas.

61. WACHS staff said that recruiting a permanent psychiatrist has been a priority for a long time. Australian trained psychiatrists want to stay in metropolitan areas and, while overseas graduates are an option, there have been changes in visa requirements which have made this more difficult. The process of relocating an overseas graduate for such a role would take at least a year.

62. It was thought that extra financial incentives may possibly make a difference but that the real barriers were the social and family sacrifices involved in relocating to Kalgoorlie.

63. The Senior Advocate was informed that clinical leadership has similar problems in all departments of Kalgoorlie Hospital and that there they also have difficulty in sourcing mental health nurses.

64. A child and adolescent psychiatrist will, however, be made available for the Goldfields on a part time basis in November 2018. They will visit Kalgoorlie in person on occasion but they will mainly be available via telephone for advice and guidance. A similar visiting psychiatrist arrangement is utilised for adults in the regional Kimberley area. This arrangement increased the confidence and capacity of regional hospitals to manage psychiatric presentations.

Use of security guards 65. Anecdotally, when one-to-one specials were needed, guards are used approximately 95% of

the time, nurse specials 4% and PCA’s 1%. It was said that nurse specials would be better because they would be equipped to recognise early warning signs and de-escalate situations, but staffing levels did not allow for this.

66. It is clear that having a guard present with a patient does not prevent them absconding as was the case in several of the examples given at the start of this report. On one occasion, a patient absconded while in the presence of a guard and a psychiatrist.

67. MHAS is cautious about the use of guards as they can create fear for patients or a penal impression, but we accept that sometimes clinical risk assessment deems this necessary. The Goldfields Regional Director was clear that sometimes the use of guards was needed in order to reduce risks posed to staff and patients. We agreed that a nurse special and a guard may be most appropriate in this situation if staffing levels allowed for this.

68. Two staff members said that guards could not apprehend or restrain patients. The Goldfields Regional Director stated that this was not the case and took immediate action in organising a communication to be sent to all staff from the security manager to clarify this.

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Transfers to Perth Mental health patient flow 69. Most of the cases referred to above in this report involved delays in the patient being

allocated an inpatient hospital bed in the metropolitan area. The child who absconded and made their way to the bridge had been waiting 4 days for a bed allocation.

70. Between 1 July and 25 October 2018 (117 days) there were 31 days of “code yellow” meaning that there were 15 or more patients on Mental Health Act 2014 (the Act) forms requesting secure beds yet no beds were available. In addition, there was a two day children “bed crisis” (4-6 September when 11 children were waiting for beds during that period). People can be in an ED waiting for a mental health bed for days.

71. The issues are compounded when the person is waiting in an ED in a regional area as they also need to secure an RFDS flight once a bed has been found and have to wait in the ED. An ED to ED transfer process has been negotiated recently to help with this issue (see below).

72. The situation is also particularly difficult for children and young people as demand for these beds is very high (despite new beds being made available in July 2018).

73. The referral pathways for 16 and 17 year olds currently lack clarity and universal procedures as they can involve up to four health service providers. Children aged 16 or 17 are treated by Child and Adolescent Mental Health Services (CAMHS) in the community but will not be admitted to the Perth Children’s Hospital so must vie for a place on one of the two youth wards which are run by two different health service providers. Emails tend to bounce around between the ED and the two youth wards. Kalgoorlie Hospital is supposed to be “linked” with FSH but the FSH youth unit rarely has a vacant bed and we understand wait lists are common.

74. Another issue is when a patient on the ward suddenly becomes more unwell and a transfer is requested. The regional patient is not prioritised because they are already on a ward (whereas others are waiting in EDs) and/or because the acuity on the ward in the metropolitan hospital is said to be too high to take another patient at that level. This in part reflects a lack of understanding that the level of care and safety on the regional hospital ward may be well below that of the metropolitan hospital ward, or even the ED in the metropolitan hospital. In some cases the person has only been moved to the ward because it was not safe for them to stay on the ED.

75. A new mental health patient flow process is expected to “go live” in February 2019. It is hoped this will improve access to mental health inpatient beds but it cannot by itself overcome the problem of too much demand and lack of beds or other community options.

Kalgoorlie Hospital transfer practice and procedure 76. Children (under 18 years) requiring inpatient admission will almost always require transfer

from Kalgoorlie Hospital in order to access a specialist adolescent mental health inpatient service as there are no such facilities in Kalgoorlie. Section 303 of the Act requires that children be segregated from adult inpatients on mental health wards. The person in charge of the hospital is not to admit a child unless they can be satisfied that:

76.1. they can provide the child with treatment, care and support that is appropriate having regard to the child’s age, maturity, gender, culture and spiritual beliefs; and

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76.2. the treatment, care and support can be provided to the child in a part of the mental health service that is separate from any part of the mental health service in which adults are provided with treatment and care if, having regard to the child’s age and maturity, it would be appropriate to do so.

77. A transfer of an adult patient may also be required for reasons of acuity and risk which may be evident during the initial assessment in the ED or due to escalating symptoms and behaviour after they have been admitted to the ward. Staff informed me that the vast majority of mental health presentations can be managed in Kalgoorlie Hospital and they only request a transfer when it is clear that it is necessary and urgent, or for reasons of repatriation. The Senior Advocate was informed that it is always the consultant who makes that decision.

78. Anecdotally only one young person “every few weeks to a month” requires transfer and sometimes the situation is deemed manageable on the ward while they wait. On other occasions however the situation becomes desperate and it is then that an alternative bed and transport via RFDS is urgently needed.

79. Staff said that a decision can be made fairly quickly by Kalgoorlie clinicians as to whether a transfer out of Kalgoorlie Hospital is needed and that the paperwork for transfer and the RFDS transport is not seen as an issue and does not cause a delay: “We understand why this information is needed and we can get all of our ducks in line pretty quickly here.” The paperwork for the child who jumped from the bridge was completed the same day that the patient presented to ED as it was obvious they would need to be transferred.

80. As noted above, an ED to ED transfer process has been negotiated between WACHS and the other health service providers which has been in place since 13 August 2018. It allows mental health patients to be transferred from regional EDs to an ED in the metropolitan area when it is no longer safe to manage the patient in the regional ED, all options to identify a local option have been explored and there are no mental health beds available state-wide. See annexure 1.

81. The ED to ED agreement does not extend to patients who are on a ward in a regional hospital, although there have been examples in recent months where patients in Kalgoorlie Hospital’s HDU and A ward have been transferred to the FSH ED when a transfer was deemed to be urgent and there were no other mental health beds available. A mental health admission was then sourced from FSH ED into Fremantle Hospital. This pathway is based on the WACHS Link Unplanned Adult Inter-Hospital Patient Transfer Model. See annexure 2.

82. Ideally the ED to ED transfer agreement should be extended to clearly allow for a prioritised transfer for a patient on a regional ward to a metropolitan ED when the patient is at escalated risk and rising acuity, when there are no mental health beds available in the state.

83. The Senior Advocate was also told about an internal escalation process within WACHS (through the WACHS Executive Director, Medical Services) to RFDS which can be activated when delays are experienced in flight availability once a bed has been sourced.

Royal Flying Doctor Service practice and procedure 84. The overwhelming majority of all staff spoken to in Kalgoorlie Hospital verbalised their strong

view that a change in the RFDS priority levels for mental health was the key to improving the situation for patients at Kalgoorlie Hospital.

85. MHAS was informed of a system of categorisation in place that grouped people based on urgency into category 1, 2 or 3. All mental health patients would be category 3 unless they were intubated in which case they would be category 1.

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86. MHAS met with RFDS who said that transfers for mental health patients could be placed in category 2 or 3 based upon information provided at the time of transfer application, with the opportunity for this to be updated and reviewed. The transfer of mental health patients is restricted to daylight hours by RFDS policy of not transferring anyone with the potential for behavioural disturbance overnight due to associated increased risk.

87. RFDS confirmed that mental health patients would only be placed in category 1 when intubated although they acknowledged the view of MHAS that sometimes a mental health crisis is a serious life threatening situation, illustrated by some of the most recent examples from children and young people at Kalgoorlie Hospital. They were keen to discuss options.

88. RFDS are bound by current resources and they informed MHAS of some capacity that they hoped to create through some new planes (PC24s) that are faster and can carry more patients per journey. There is a plan to introduce one at the end of 2018 and one at the beginning of 2019, with the possibility of two more at a later date.

89. The difficulties in lining up an inpatient bed and the services of RFDS can create the unintended consequence of wasted resources. On occasion the facility in the metropolitan area has been unable to hold the bed while waiting for RFDS and given it to another patient just as the RFDS has become available. On other occasions holding the bed open while awaiting RFDS transfer has resulted in a metropolitan bed being empty for several days during times of high demand.

Alternatives to RFDS 90. WACHS staff said that a decision to transfer a patient was not taken lightly and that in these

situations experienced medical staff were needed. It was therefore not seen as appropriate to consider other flight options such CareFlight or the Goldfields Air Services, as indicated in the Kalgoorlie Miner newspaper by the local Member of Parliament, Kyran O’Donnell as a possibility. Ambulance transfer in any form was not thought to be the answer with staff saying it would be very unsafe for mental health patients as well as extremely uncomfortable.

91. WACHS is continuing to consider alternatives to current arrangements for patient transfers from regional areas.

Sedation of mental health patients 92. MHAS are aware that during times of escalation of risk and behaviour, patients including

children have been treated with ketamine in regional hospitals.

93. The choice of sedative drugs during these situations is said by WACHS to be complicated by the constraints around delays in transfer out of regional areas. The repeated delays are resulting in staff having to use higher risk medication such as ketamine. These delays in transfer are largely felt to be due to bed supply and RFDS scheduling rather than clinical presentation.

94. Staff spoke about the prescribing of ketamine to a young person with an intellectual disability who was in the hospital alone: “We knew that giving him so much ketamine was dangerous but we had no option…. We are not equipped for chemical restraint here but we do it.”

95. The Senior Advocate was informed that everybody involved was very uncomfortable with the amount of ketamine prescribed and the length of time this medication was used while awaiting an appropriate bed and transfer. The hospital supply of ketamine nearly ran out.

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Staff were visibly upset when recalling this situation and close to tears. One staff member said: “I am waiting for the next young person to come through the doors with the same issues…nothing has changed.”

96. In that case the patient became agitated when the ketamine was removed and assaulted staff which resulted in the patient being intubated. Intubated patients automatically become category 1 for RFDS; however intubation provides risks to physical health that Kalgoorlie Hospital isn’t resourced to manage as well as would be possible in a metropolitan hospital.

97. There was some concern raised by staff at Kalgoorlie Hospital that RFDS may sometimes intubate mental health patients for the transfer flight when this could potentially be avoided. RFDS insisted that they would always avoid intubation where possible and that they had a range of methods of sedation available to avoid intubation, including ketamine.

Step up step down facility 98. We are aware that a step up step down facility has been funded for Kalgoorlie and that

construction is planned to commence in June 2019, with an aim for completion between June and October 2020.

99. RFDS Chief Executive Martine Laverty was quoted in the Kalgoorlie Miner newspaper in October 2018 saying that Flying Doctor research revealed prevalence of mental illness was the same in the city and regional areas, yet there was a big difference in acuity with regional patients often becoming sicker before accessing services.

100. It is hoped that the establishment of a step up step down facility will support residents of Kalgoorlie who are living with mental illness and may go some way to decrease the disproportionate acuity that is reported by RFDS.

101. However, it is not clear to MHAS that a step up step down facility would assist in avoiding the necessary transfer of certain patients to Perth. In these cases the complexity of illness, high risks, use of illicit drugs and accommodation problems may preclude these patients from utilising the step up step down services. We base this on our experience of such services offered in the metropolitan area. Current data suggests they these facilities are operating as a step up service but less so as a step down service.

102. Based on problems getting and retaining clinical staff at the hospital, MHAS is also concerned about the ability to staff this unit.

Broome mental health unit 103. It is useful to compare the Broome situation with Kalgoorlie because a main issue emerging in

this Inquiry is that the conditions of Kalgoorlie are worse and raise more risks for acutely unwell mental health patients than any other regional mental health unit. It is proposed that this increased risk be taken into account when allocating beds and RFDS priority.

104. The Broome mental health unit was purpose built and has 11 beds in the main area of the ward and two beds in a locked high dependency area that offers a seclusion room. One of the two beds is a swing bed that can be used dynamically as a bed in the high dependency area or another open bed, depending on the current patient cohort and acuity level.

105. Several outdoor areas are available for patients, including a visiting area and a separate outdoor area with increased security in the high dependency area. Patients do occasionally climb over the fence and leave the unit. On one occasion someone repeatedly kicked the wire

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mesh in the outdoor space of the high dependency area and managed to abscond from the ward. There are plans underway to modify the mesh so that this cannot happen again.

106. Broome has been serviced by a permanent psychiatrist who was there for 12 months before recently moving into a community team position. Another psychiatrist who is known to the Broome team will be replacing them on a 12 month contract. Staff said that prior to this, there had been had many locum psychiatrists at Broome for a period of approximately six months which provided challenges.

107. Broome also has outliers on other wards sometimes, more so in the months of tropical hot weather which sees an increase in mental health admissions. It is believed that outliers require specialist mental health interventions and as such there has been an increase in the provision of PLNs to three. Staff said that this increase was felt necessary in order to maintain the quality and specialist service provision required for mental health patients and is currently working well.

Conclusions and suggestions for redress 108. Kalgoorlie Hospital has greater challenges in maintaining a safe environment as compared to

authorised hospitals in the metropolitan area and other regional authorised hospitals. This is particularly true in relation to children, young people, and those who are who are vulnerable to absconding. It is clear that Kalgoorlie Hospital is not a place of safety for some of these patients.

109. When a patient in this category has been assessed by Kalgoorlie Hospital staff and identified as needing a transfer, it is important that the rest of the mental health sector understands this and responds accordingly. A summary of the challenges faced by Kalgoorlie Hospital is outlined below.

109.1. Physical environment - There are significant risks associated with the location of Kalgoorlie Hospital being so close to the railway line and the bridge, as well as the low fence in the garden of A ward allowing easy access to the local environment. HDU and ED are not therapeutic environments for mental health patients and they are not locked spaces. Local patients can, and have, easily absconded off these wards, even with guards in situ.

109.2. Staffing capacity - There is a clear need for the provision of mental health nurse specialling to manage risk as opposed to the current system of utilising guards which is not working. Having more mental health nurses would also provide opportunity for more one to one nursing time with patients, extended outreach to outliers on other wards and more time for patient activity on A ward. We appreciate that extra staff involves a financial commitment and we take on board comments made about the difficulties in recruiting mental health nurses for Kalgoorlie Hospital.

109.3. Lack of leadership and permanent psychiatrist - Despite being a priority for WACHS, it has not been possible to recruit a permanent psychiatrist at Kalgoorlie Hospital and therefore locum psychiatrists have been used consecutively for the last four years and sporadically since 2011. This arrangement is disruptive to patient care, increases risk for patients, and not conducive to the provision of high quality, dynamic services.

109.4. Mental health patient flow - The current state-wide demand for specialist inpatient beds outweighs the supply. This situation leads to delays in securing an appropriate

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bed for patients requiring transfer from regional areas. At Kalgoorlie Hospital in particular, this delay creates extreme risk for some patients.

109.5. RFDS - Once a bed has been sourced, the risk and urgency for transfer of these patients from Kalgoorlie Hospital is not reflected in the prioritisation system of the RFDS and hence further delays in an unsafe environment are experienced.

109.6. Chemical restraint – the repeated ongoing use of chemical restraint due to delays in transferring patients to a safe environment (as opposed to a clinical need) is alarming given the risks to patients.

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Recommendations Kalgoorlie Hospital is not a safe place for vulnerable patients as evidenced by the number of serious incidents recently. MHAS believes this cannot be addressed by the hospital or WACHS alone and requires a collaborative approach from other parties in the mental health sector, such as:

• the Mental Health Commission (MHC) as the recurrent funder; • the Department of Health (DOH) as the system manager which is responsible for capital and

some other recurrent funding; • specialised youth mental health services at Fiona Stanley Hospital run by the South

Metropolitan Health Services (SMHS) and EMYU run by the East Metropolitan Health Service (EMHS);

• the Chief Psychiatrist who sets standards and oversees treatment and care of mental health patients; and

• patient transport services i.e. RFDS.

MHAS recommendations are therefore addressed to these parties.

Comments are sought from all parties in relation to the recommendations which are noted as relevant to them. The Minister for Mental Health Services will be separately briefed.

Responses from the Mental Health Commissioner, Chief Psychiatrist and Director General of the DOH are further sought under s363(5) of the Act requiring them to advise the Chief Mental Health Advocate whether or not further inquiry or investigation is warranted and if inquiries are made, the outcome, including recommendations made, directions given or other action taken.

Recommendations relating to Kalgoorlie Hospital ward and staffing conditions If a safer environment (including adequate staffing) can be achieved, this will go a long way to prevent the serious incidents from continuing to occur. Recommendations one to six below relate to this issue.

Recommendation 1: To Kalgoorlie Hospital, the WACHS, the Chief Psychiatrist and the DOH

Permanent, safe changes to be made to the outdoor fence of A ward as a matter of urgency to reduce the possibility of more patients absconding. Another patient leaving A ward over the fence and being harmed cannot be tolerated. A mesh conservatory or other option that reduces the confining feeling and prison like environment produced by the current temporary arrangements is preferable. The temporary arrangements should not be allowed to become permanent

Recommendation 2: To Kalgoorlie Hospital, the WACHS and the MHC

Engagement of more mental health specialist staff as follows:

• more mental health nurses rostered per shift on A ward to provide a greater opportunity for nurse specials (instead of relying on security officers, even if it is alongside one) and more one–to-one time with patients which enables risk management, care and treatment. Extra funding will be needed but the recommendation reflects the fact that Kalgoorlie only has a 6

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bed ward which makes economies of scale difficult and that 30% of the mental health admissions are treated on other wards at some point (the outliers); and

• an increase in the provision of mental health specialist staff to outlier patients on non-mental health wards. This could include utilising the extra mental health nurses on A ward noted in recommendation 2, or employing an additional PLN. Again there are funding implications.

Recommendation 3: To Kalgoorlie Hospital and the WACHS

Mandatory mental health and suicide prevention training for all non-mental health staff due to the large number of mental health patients (outliers) being treated by non-mental health specialists.

Recommendation 4: To the WACHS, the MHC and the Chief Psychiatrist

New and innovative targeted measures to incentivise and retain a Clinical Director and other psychiatrists (and to a degree nursing and other health care workers). It is likely to require more funding including a higher rate of pay. Medical staff who have worked at the unit could be canvassed for their views if this has not been done previously or an independent consultant could be retained to consider and pose solutions.

An alternative is for the Chief Psychiatrist to consider removing the authorisation of the unit because it does not have consistent appropriately qualified medical staff needed for an authorised ward where involuntary patients are cared for. This would require all patients under the Act to be transferred to Perth which would be a very poor outcome and should clearly be a last resort.

Another alternative is that the Chief Psychiatrist set guidelines around the minimum requirements for medical staffing and continuity of care and require to be notified immediately if and when the guidelines are not met, at which time the unit is temporarily de-authorised.

Recommendation 5: To Kalgoorlie Hospital and the WACHS

A review of current activities available on the ward and the exploration of a schedule of activities for patients, including the potential of the kitchen being further utilised. Additional activities would be possible with additional nursing staff on the ward (see recommendation 2). Apart from providing better care and recovery prospects generally, it may reduce patient distress and yearning to escape the ward adding to the safety of all patients.

Recommendation 6: To the WACHS and the MHC

Consider a larger, purpose built mental health unit at Kalgoorlie Hospital in any future redevelopment proposals (noting the modelling by the MHC in the Mental Health Plan which estimates 20 inpatient beds will be needed by 2025). This would ideally be similar to the Broome mental health unit and not located beside the railway track. It could be co-located with the community mental health team to decrease professional isolation and build dynamic capacity.

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Recommendations relating to timely and safe access to treatment Without improvements to the conditions and staffing arrangements at Kalgoorlie Hospital, drastic changes will need to be made to transfer patients at risk of absconding and/or in need of specialist child and adolescent inpatient services to avoid more tragedies and delays in people getting treatment.

The delays in accessing specialised child and adolescent inpatient services is an issue for all WA regional areas, but is significantly compounded at Kalgoorlie Hospital because of the risk of absconding, resulting in a high risk to life, and the small size of the mental health ward resulting in people being cared for on non-mental health wards. The recommendations below relate to these issues.

Recommendation 7: To the MHC, the DOH, the EMHS, the SMHS and the WACHS

Underlying all of the issues and risks is the lack of inpatient mental health beds. This issue needs to be urgently addressed as “code yellows” (when 15 or more beds are not available for people on mental health forms) are called regularly in WA.

There also needs to be an urgent review of the number of beds needed for 16 and 17 year olds, especially in peak times, and for children living in regional areas generally, so the Act can be complied with and they can be cared for in child or youth wards.

As an interim or adjunct measure, telehealth alternatives need to be explored. This issue is not just about access to child and adolescent psychiatrists - it includes the safety of the child who should not be sharing a ward with adults.

Recommendation 8: To the DOH, the WACHS, the EMHS and the SMHS

Urgently finalise the mental health patient flow arrangements to include the following:

1. a clear and equitable pathway for all regional patients which takes into account that a mental health patient in a regional hospital ED or ward may not be receiving appropriate or safe care and should be prioritised – this is particularly so in Kalgoorlie Hospital given its physical and resource limitations;

2. a rapid and clear escalation process for 16 and 17 year olds agreed between EMHS and SMHS to promote a quick admission for children in Kalgoorlie to either the FSH youth unit or EMYU (and probably in relation to children in other regional hospitals as well, in particular Geraldton which does not have a mental health ward); and

3. an extension of the ED to ED transfer agreement to allow patients admitted to a ward at Kalgoorlie Hospital to be transferred to FSH ED when there is no inpatient bed available at FSH or elsewhere and the patient is deemed to be high risk and cannot be safely cared for at Kalgoorlie Hospital.

Recommendation 9: To the WACHS and the RFDS

Other options for the transport of patients from regional areas should be considered. Options relayed to MHAS included funding new plane(s) (PC24), considering alternative service providers

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and/or funding a daily run between the four main WACHS hospitals (Geraldton, Broome, Kalgoorlie and Albany).

Recommendation 10: To the WACHS and the RFDS

Review of the prioritisation system currently in place for mental health patients in regional areas to better reflect the individual need and risk of mental health patients including informing and educating RFDS clinicians about the physical conditions and staffing limitations for such patients in particular regional hospitals (such as Kalgoorlie and Geraldton). The priority system should include:

• consideration of the regional hospital physical conditions and staffing and their contribution to risk; and

• protocols to allow Kalgoorlie clinicians to inform RFDS when the situation is beyond their capacity to safely manage the patient locally, with the case being prioritised to category 1.

Recommendation 11: To the DOH, the WACHS, the MHC and the RFDS

That the parties demonstrate how they are working collaboratively and constructively to resolve these system problems.

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Annexure 1: WACHS Assertive Patient Flow and Bed Demand for Adult Services: Policy and Practice Guidelines

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Annexure 2: WACHS Link Unplanned Adult Inter-hospital Patient Transfer Model

INQUIRY INTO CONDITIONS AT KALGOORLIE HOSPITAL …

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