![Mother recalls horror of learning son died by suicide inside city's mental health unit Mother recalls horror of learning son died by suicide inside city's mental health unit](/images/transform/v1/crop/frm/jessica.howard/edeef76b-ff4d-49dd-8b39-6fcd33f7c135.jpg/r0_0_800_600_w1200_h678_fmax.jpg)
A south-west mother has spoken of the pain of learning her son had died by suicide inside a mental health unit that was supposed to keep him safe.
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The 28-year-old man suffering suicidal ideations could not be seen inside a seclusion room at South West Healthcare's (SWH) Warrnambool mental health unit for more than 10 minutes before he took his own life.
He was found dead inside the room in March 2020.
A coronial inquest into the man's death was held on Tuesday, September 5.
In an impact statement, the mother said her son was a young man in crisis, suffering constant back pain and struggling as a victim of the government's robodebt scheme.
She said she could see her son breaking in early 2020 and on March 16 that year, they argued about his refusal to attend a mental health clinic in Camperdown and he took off in his car.
"I was terrified for his safety and I rang the police for a welfare check," she said.
Her son was aggressive and agitated and had made threats to self harm.
Police found the man seated in his car and he was transported to Warrnambool Base Hospital under the Mental Health Act.
He was assessed by a doctor and placed in a seclusion room in an attempt to calm him down and provide medication to assist with his mental state and poly-substance misuse.
It was in that room the man took his own life, the court was told.
The mother said police had reassured her that her son was being taken to safety.
When she rang the hospital the next day, she was told he'd been placed in the seclusion room and given anti-psychotic and sedative medication.
"I asked if I should come up.. he would need some things. The hospital said he didn't and he was safe and I should take an opportunity to rest," she said.
Later that day she received the "most horrific" phone call of her life.
"It is something that will stay with me forever," she said.
She said her son was completely broken, going through "absolute crisis" and left alone, in pain and "stripped from anything except his own thoughts".
"I cannot begin to tell you the pain that those thoughts cause myself and my daughter," she said.
"This was exactly what I was trying to help my son from - the isolation, the pain, his head space...and the hospital put him right back there, ten-fold, with nothing but the ability to take his own life."
She said her son was "very dearly loved" and she and her daughter would now have to move forward in life without him.
"And that is a sadness that will stay in our hearts forever," she said.
The court was told the man was last seen standing behind the door of the seclusion room at 7pm on the night of his death.
A nurse said in a statement he became suspicious of the patient at 7.10pm because it was a challenging area of the room to observe.
Sometime after 7.20pm the door was rattled but hospital staff received no response.
Security was called and the room was entered at 7.28pm.
The man was unable to be revived and pronounced dead at 7.55pm.
Counsel assisting the coroner, Gordon Chisholm, said the man's death was preventable.
He said SWH had carried out its own investigation after the tragic death, leading to deficiencies in care being identified.
He said there three areas of deficiencies that were connected to the man's death.
That included his access to a blanket which was capable of being readily modified and used for purposes of self-harm, the availability of door hinges within the seclusion room, and restrictions in the hospital staff's line of sight.
"Hospital staff were unable to conduct thorough and visual observations of him at all times," he said.
Mr Chisholm said SWH had since implemented remedial actions to address those risks.
He said the hospital should be commended for taking out the investigation in attempts to prevent another death.
SWH chief executive officer Craig Fraser appeared online in the hearing on Tuesday.
In a statement to The Standard he expressed SWH's "heartfelt condolences" to the family for their loss.
"We acknowledge the immense depth of their grief and appreciate their involvement in this inquest, which we understand can take a great personal toll," he said.
"This event was devastating for all involved including the team at South West Healthcare. Patient safety in an acute mental health facility requires constant vigilance and review.
"As a consequence, we implemented a number of physical and policy changes, including addressing the key findings across our service and will continue to review and improve our physical environment. South West Healthcare is grateful to the counsel assisting the coroner for acknowledging these changes and improvements in today's hearing, and we are open to receiving the courts findings."
Mr Fraser said SWH regularly reviewed its mental health facilities and made continuous improvements in safety and practice measures as advised by the chief psychiatrist, the Department of Health and on the recommendations of the Royal Commission.
Coroner Kate Despot will release her findings at a later date.
- Support is available for those who may be distressed. Phone Lifeline 13 11 14.
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