Mental health service ignored desperate cry for help
DANNY Bowen was suicidal the day he asked his family to take him to the Lismore Base Hospital's Adult Mental Health Unit (AMHU).
It was 11.15am on Wednesday, May 28 when he presented at the Community Mental Health centre - the 'front' door to Mental Health Services in the region - with symptoms of agitation, anxiety and depression.
That morning he had told his daughter Brooke Bowen he was looking for objects to hang himself with.
It was a desperate plea for help, but one the family feels fell on deaf ears.
"The doctor came in, not even a notepad and pen, didn't take down any particulars of who he was, what he's suffered with, and then makes a statement to say that the overall assessment of suicide risk at the time as medium," Ms Bowen said.
- Anyone in need of crisis support for depression or suicide can contact Lifeline on 13 11 14
"Someone that says they want to turn around to find something to kill themselves with is not medium risk of suicide."
When Mr Bowen was told there were no spare beds in the mental health unit, he began having difficulty breathing and experienced chest pain.
He was transported to the Emergency Department to be treated for the chest pain, but after 10 hours at the hospital, there were still no beds in the mental health unit and Mr Bowen was sent home.
For the next three weeks, his mental health was monitored daily by the Community Mental Health Acute Care Service through home visits and phone calls.
There were several face to face visits in the first week following admission, but the level of monitoring appeared to take a turn for the worse when the follow-ups became phone calls with Danny Bowen's wife instead of him.
Three weeks passed and still no bed was available.
On Thursday, June 19, Mr Bowen was brought to the Lismore Base Hospital Emergency Department after being found hanging in his home.
He was pronounced dead the next day.
A NSW Health Root Cause Analysis (RCA) report found large sections of Danny Bowen's case had gone undocumented.
It raised questions about why a bed was not located during the three weeks of monitoring and why mental health assessment phone calls were made with the wife and not the patient.
"Even though admission to an AMHU could not occur that night the RCA team did not find evidence of any alternative temporary admission processes being explored," the report said.
"The RCA team are concerned many episodes of the follow-up between June 4-18 existed via phone with the clients wife and not directly with the client himself."
Northern NSW Local Health District mental health executive director Richard Buss said the Root Cause Analysis report showed Mental Health Service staff were regularly monitoring Mr Bowen's condition up until the day of his death.
"Senior mental health staff have met with family members to discuss the findings of the review and have invited the family to meet with senior clinicians and management ," he said.
"On behalf of the Lismore Mental Health Services I wish to extend our sincere condolences to the family as a consequence of this sad episode."