$150,000 fine follows lethal assault

Health Service ‘exposed patients and staff to risk of injury’.

A psychiatric patient’s late-night rampage at Kempsey District Hospital in 2001 cost the life of fellow patient Eunice Benedek, 72. Repercussions from that night of violence continued last month when a judge fined the North Coast Area Health Service $150,000.
Justice CG Staff of the NSW Industrial Relations Commission imposed the fines for six offences under the Occupational Health and Safety Act.

Inadequate security measures and inappropriate duress alarm systems had posed a risk of injury to both patients and staff at the hospital, Justice Staff said.

Justice Staff was told that a patient, ‘T’, inflicted fatal head injuries on Mrs Benedek. He escaped from the hospital by breaking through an external door. Police charged ‘T’ with murder but he was found not guilty because of his psychiatric state.

Before assaulting Mrs Benedek, ‘T’ twice punched a nurse to the ground and kicked her, fracturing her cheekbone. He punched another nurse in the face.

‘T’ was admitted to 149 Unit, a non-secure psychiatric inpatient ward, after allegedly threatening his wife with a machete and claiming to be God.

Justice Staff said ‘T’s’ personal belongings were not searched when he was admitted to hospital, contrary to the Health Service admissions policy.

The Health Service argued that the case was about medical and nursing staff failing to recognise the nature and extent of the man’s psychotic condition.

Justice Staff rejected this, pointing out that the Health Service had failed to provide regular training to ensure that an accurate assessment and correct diagnosis was made upon admission.

Had the doctor and nurse been trained in the categorising of patients in accordance with the admissions policy, employees would not have been exposed to the risk of a psychotic patient being admitted, he said.

The Health Service admitted that there was no adequate policy, procedure or training at the hospital to ensure a timely and appropriate response to duress alarms.

A lone nurse who responded to the alarm was also assaulted on arriving at the scene, yet policy required the night supervisor to respond with one other person. ‘The lack of knowledge (about policy) plainly put the employees at risk,’ Justice Staff found.

There was no regular review of duress alarm systems, nor did the Health Service conduct any proper duress response training.
Five months before the incident the Health Service hired a security company to review security at the hospital, though its report apparently was not provided until just after the incident.

The report identified security failings including:

  • Absence of clearly documented security policies and procedures.
  • Staff regularly worked alone in isolated parts of the building.
  • Training in duress response was provided to some but not all staff.

Justice Staff said: ‘The existence of a system on paper alone is clearly not sufficient to comply with the obligations imposed under the OH&S Act. The employer is required to ensure that its “paper systems” are implemented and maintained in its daily operations.’

He said that following the incident the Health Service moved quickly to rectify its breaches. The 149 Unit was closed immediately and never reopened.

A new mental health facility at Kempsey Hospital was opened in March 2003, and ‘significant and fundamental systematic changes’ were made to mental health services in the Area.

Kempsey still taking risks

It seems the North Coast Area Health Service still has lessons to learn despite being prosecuted over the 2001 incident that led to the closure of 149 Unit (see main story).

More than two years after it opened, Kempsey Hospital’s new mental health unit which replaced the condemned 149 Unit has been operating in breach of the law and safe working procedures.

Three scheduled patients were admitted to the voluntary 10-bed unit over the past few months, contrary to the Mental Health Act. And the unit still does not have an admissions procedure to assess patient risk levels.

When the NSWNA raised the issue with Area management, it launched an immediate investigation to determine where the system had broken down.

Area management assured the union that no more gazetted patients would be admitted to the voluntary unit at Kempsey, and there were no plans to gazette any beds in the current ward or hospital. These assurances were repeated at a site inspection by NSWNA officers last month.

NSWNA’s branch secretary at Kempsey Hospital, mental health nurse Peter Peisley, said the Area had developed admission protocols for gazetted units but there were none for Kempsey’s low acuity voluntary unit.

He said several scheduled patients – some with a history of violence – had been admitted to the Kempsey unit over the past few months.

‘This is contrary to the Act and also to a set of safe work practices developed with input from the union following the 2001 incident,’ said Peter, a former 149 Unit nurse.

‘We need admission protocols so we can properly assess patient risk and transfer high-risk patients to a gazetted unit that can provide them with appropriate treatment in a safe environment.

‘How can we really refuse a scheduled patient if we have no protocols?’

Peter said Area management had promised to present a draft admission procedure ‘within two to three weeks’. It is to be developed in consultation with the union branch and other relevant staff.