A young man who was “begging” for help with his mental health gave up waiting after languishing in a chaotic emergency department where a meth user was going berserk, slipping out unnoticed and taking his own life.
Devan Beau Ginbey had been at the Peel Health Campus ED for almost 24 hours and in its “flight deck” area for more than 12 hours on January 13 last year when he walked out of the secure entrance — which requires a PIN or access swipe — as paramedics wheeled in a patient.
In findings from his inquest released this week, the area was described as a “thoroughfare” and an overflow section in the middle of the busy department with no curtains or a call bell — just beds placed in an open area.
Close to the nurse’s station and in a highly visible spot, it was where patients awaiting a rare mental health bed were placed and could be easily seen by staff.
But the patients — who were supposed to get their own nurse — were regularly forgotten because “the position was often not staffed”, Deputy State Coroner Sarah Linton was told.
“It is acknowledged to be a particularly noisy area with a lot of foot traffic and no privacy,” the findings read.
“It appears the noise and activity eventually became too much for him, and Devan left the ED without informing staff.
“He left between 6am and 6.30am, around the time an agitated patient with small children was put in a bed near to his own.”
![The “flight deck” area of the Peel Health Campus ED, where Devan waited for more than 12 hours on January 13 last year.](https://timesofsydney.com/wp-content/uploads/2024/05/3075786d69bdac917d1d98098cfcd54847ced966.jpg)
The woman had become aggressive and was “screaming and yelling and swearing and flailing around,” so a Code Black was called and security became involved.
She eventually had to be sedated, which required the help of about three quarters of the staff on the floor at the time.
The meth user was then allocated a ‘one-to-one nursing special’ as she was an “airway risk”, which required extra staff to be found. Also, efforts were made to find an alternative carer for her children.
So Devan was not seen when he left, leaving CCTV to later reveal his movements.
It wasn’t until around 8am when his mother Erin Stanley arrived and asked where her son was that the alert was raised.
Around 9am, Ms Stanley and the psychiatric liaison nurse (PLN) talked about calling police, but it was decided he didn’t meet the criteria to be involuntarily detained under the Mental Health Act.
Devan’s mother was also concerned that involving police might escalate the situation and make it harder for him to accept treatment.
Devastatingly, his grandfather went to his Wannanup home and found him hanging in the garage a short time later.
![Devan was “begging” for help with his mental health but walked out of the “chaotic” ED.](https://timesofsydney.com/wp-content/uploads/2024/05/03ff45462d45eb6ff420e42f5c54bf95013d1080.jpg)
The inquest was told that Devan had been admitted at 7.21 am the prior day after self-inflicting deep lacerations to his arm, with his mother recalling he was seen by a nurse quite quickly after being triaged.
Devan had been rocked when he was 15 by the suicide of his best friend, then another friend the next year.
He had been triggered by a conversation with his ex-girlfriend and a nurse said that he was quite teary, talking about stresses in his life including losing his job and being worried about losing his rental house.
He reported feeling suicidal and admitted to previous self-harm, wanting help with drug and alcohol use as well as his mental health.
While he previously hadn’t always engaged well with mental health services, Devan was on this occasion “almost begging” to be hospitalised, saying “he would go anywhere as he just needed help”.
The coroner found the bed shortage was State-wide and there was no psychiatric cover in the ED between 10pm and 8am, so deterioration was expected to be identified by non-mental health staff.
![A quiet Sunday at Peel Health Campus following the discovery of mould in the hospital's air conditioning. A small number of people still attended the ED.](https://timesofsydney.com/wp-content/uploads/2024/05/323e1eda51d4f1e9b614c2cd48740dcd8c882745.jpg)
Emergency medicine consultant Thomas Burbidge-King assessed Devan that first morning and made a referral to a PLN — indicating to the ED team that Devan was not to leave until that nurse had conducted their review.
The doctor agreed at the inquest that it might have been appropriate for ED staff to make more regular observations of his mental state, given he had expressed suicidal ideation and would likely feel more anxious in such an environment.
“It was generally agreed that there are ‘definitely better places’ for a patient like Devan to be kept while waiting, given how chaotic and stressful the ED can be at times,” Coroner Linton said.
One of the nurses testified: “We really let Devan down.”
But Coroner Linton said the staff at the time were doing their best for him, and all appeared to be caring and appropriately trained.
“However, the staff who worked in the ED all seemed to accept that the design of the Peel ED was not conducive to caring safely for mental health patients like Devan,” she said.
![Premier Roger Cook and Health Minister Amber-Jade Sanderson speak to the media about a new Ronald McDonald House Facility in Crawley this morning before having a brief tour.](https://timesofsydney.com/wp-content/uploads/2024/05/2e5321cb2455902f8d8069eabba6475cce8af145.jpg)
Coroner Linton made a sole recommendation, that Health Minister Amber-Jade Sanderson commit to funding a 10-bed mental health observation area and 20-bed inpatient mental health unit when South Metropolitan Health Service takes over Peel Health Campus at the end of 2024.
The hospital is currently a private/public partnership with Ramsay Health Care Australia, with mental health services provided by SMHS.
In a statement to The West Australian, Ms Sanderson said Peel Health Campus would again be a Government-owned and operated facility in August — and confirmed the beds would be part of a $152 million redevelopment.
“Works are progressing on the redevelopment, with enabling works expected to commence before the end of the year and a tender to be released soon,” she said.
Nurse and midwife-to-patient ratios were being progressively rolled out, she added.
The inquest was told that patients on the “flight deck” were now officially allocated a nurse, preventing them from being forgotten.
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