Inquest finds four factors in fatal fall

The two circumstances were among four factors that coroner Megan Greenwood yesterday said contributed to 69-year-old Mrs Simmons's death from multiple injuries suffered in a fall from the hospital balcony on April 26 last year.

Handing down her findings from an inquest conducted in June, Ms Greenwood said she was satisfied on the balance of probabilities that Mrs Simmons, a mental health patient at the hospital, fell from the balcony by her own deliberate actions and that she intended to cause her own death.

Ms Greenwood said that after another mental health patient jumped from the same balcony in 2006 a policy was introduced to keep balcony doors locked, but following Mrs Simmons's fall five years later it was found that a door connecting a waiting room and the balcony was unlocked.

"So, while a policy was in place there were shortcomings in that it was not enforced as rigidly as it could have been, and access to balconies was (also) still available through windows," Ms Greenwood said.

She said a decision on Easter Saturday, April 23, to discharge Mrs Simmons from a general medical ward where she was being treated for an infection that caused hallucinations and return her to the Gissing House psychiatric ward was taken “at least in part to avoid bed blockage in the general hospital over the long weekend”.

The other two contributing factors nominated by Ms Greenwood were Mrs Simmons breaking up with her boyfriend on her return to Gissing House and a “less than cautious” approach to granting her leave given her physical illness, the associated delirium and the breakup.

Mrs Simmons suffered from a severe form of bipolar affective disorder that Ms Greenwood said was difficult to control.

Mrs Simmons was admitted as an involuntary patient of Gissing House in January last year after trying to kill herself by driving into a tree.

Her treating psychologist, Dr Allyson Hickey, wrote on February 4 that Mrs Simmons was very unpredictable and her attempts to kill herself had often been impulsive and somewhat bizarre.

Just 11 minutes after being granted unescorted leave following an assessment by two nurses on April 26, Mrs Simmons jumped or caused herself to fall from the balcony.

The inquest was told that leave is an important part of mental health treatment, that Mrs Simmons had unaccompanied leave on April 25 without incident and that she was heading towards discharge.

One of the nurses told the inquest she thought Mrs Simmons appeared settled and stable during the April 26 assessment, which involved a lengthy conversation, asking Mrs Simmons questions and observing her demeanour.

“It is significant that no one who had contact with Madeline that morning noted any signs of distress in her,” Ms Greenwood said.

She said, however, that other staff had noted on the previous day that Mrs Simmons was “low in mood” following the breakup.

Ms Greenwood said the evidence of Mrs Simmons’s medical carers – both doctors and nurses – showed a strong motivation to give her the best available care and decisions were made on the best information available at the time.

However, Ms Greenwood described as “not an ideal situation” that an on-call psychiatrist who had never met Mrs Simmons (and working from Sydney using a telephone) had reinstated leave privileges upon her leaving the general medical ward without the benefit of examining her or reading her case notes.

“Madeline’s case was particularly complex, making this practice even less desirable,” Ms Greenwood said.

The Murrumbidgee Local Health District has since changed its policy so that on-call psychiatrists who do not have regular contact with patients cannot grant leave.

Risk assessments must now be documented before a patient takes leave, and psychological stressors, such as relationship breakdowns, must be considered in the assessment.

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