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Legislative Council - Fifty-Second Parliament, Second Session (52-2)
2012-09-19 Daily Xml
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SUICIDE PREVENTION

The Hon. J.S. LEE (16:44): I move:

That this council calls on the Minister for Mental Health and Substance Abuse and the state government to address the failure in handling mental health patient, Mr Damian Kay, by adopting the recommendations of the State Coroner, Mr Mark Johns—

1. that the Department of Health should ensure that training in the assessment of suicidal risk should be provided both to medical undergraduates and doctors working in emergency departments;

2. that a junior doctor or a mental health nurse should not discharge a suicidal patient, particularly one brought in by police under section 57(1)(c) of the Mental Health Act 2009, from an emergency department, without having sought advice from a senior medical colleague, either an emergency department senior registrar or consultant, or a psychiatric registrar or consultant on call;

3. that a minimum set of information should be obtained before discharging a suicidal patient from the emergency department. It would also be appropriate wherever possible to obtain information both from family members and from current treatment doctors or other therapists. This sometimes might not be possible until the next day when an individual presents to the emergency department overnight; and

4. there should be assertive follow-up of suicidal patients. They should be offered by community mental health services, with expectations about timely face-to-face follow-up. Follow-up should be routinely offered to such patients and community mental health teams should be assertive and persistent in their attempts to see them face to face.

Today, I move this motion with a very heavy heart. I would like to first offer my deepest sympathy to the family of Mr Damian Kay for their sad loss and for the prolonged suffering and pain they had to go through during the investigation, particularly in recent times when the inquest attracted significant media attention. I would like to thank Mr Jarrad Kay, the brother of Mr Damian Kay, for his courage in bringing a very emotional and important matter to my attention and for giving me permission to speak about the chain of tragic events that impacted his brother.

Let me emphasise the premise of this motion today. The aim of Mr Jarrad Kay's campaign to bring up the matter concerning his brother's death is not about blaming or accusing anyone in particular or bearing any ill-feelings towards the young medical officer who discharged Damian from the hospital. The Kay family simply wishes to use the Coroner's report to bring up this important matter in parliament, with the hope of raising further awareness of suicide prevention in the community and, by this motion, to call on the minister and the government to implement the Coroner's recommendations and to improve the health system in South Australia.

We all recognise that mental health problems are very complicated. It is important, therefore, for us to look closely at the tragic account of what had taken place with Damian Kay. Damian Kay was married to his wife for 14 years, and he lived in Port Lincoln during that time. They had two children. Mr and Mrs Kay worked together managing a local hotel and a limousine business.

In January 2005, a raging bushfire swept across Lower Eyre Peninsula. Mr Damian Kay's wife and two children tried to escape the fire in a car in the belief that the house and the family were under extreme and immediate threat from the approaching fire. Mrs Kay encountered difficult conditions on the Lincoln Highway, and there was almost zero visibility as a result of smoke. Her vehicle collided with some trees at high speed, and Damian's wife and two teenage children were killed in the car accident. Damian was away in Adelaide at that time.

Naturally, Mr Kay was deeply affected by the death of his wife and children. For some 18 months after their death, Damian was seen by consultant psychiatrists with the Rural and Remote Mental Health Service. The doctor's report noted that, at the time, Damian was significantly affected by grief. He was going through a very difficult time, and he had increased his consumption of alcohol. He had subsequently lost his job and his friends. The psychiatrist assessed Damian as presenting with a major depressive episode in the context of unresolved grief over the loss of his family and longstanding alcohol dependence.

Around July 2006, Damian formed a relationship with a new girlfriend to a point where they described themselves as engaged. However, things did not work out. A series of events culminated around 19 September, which, coincidentally, is today's date two years ago. The girlfriend wanted to end the relationship. Damian left the house, and a long suicide note was found by the girlfriend as she entered her bedroom. She rang 000 and reported the matter to the police. As a result, SAPOL instigated efforts to locate Damian. They found him and drove him to the Lyell McEwin Hospital. During that drive Damian told police about his wife and children and how they had died in the Port Lincoln fires. The constable who attended to Damian completed a proforma mental health assistance form. The statement recorded was:

Broke up with fiancée on the night and left a 3 page suicide note stating he was going to end his life. Broke down his possessions in a note stating who got what. Believed he was going to end his life however no plan of action has been stated.

Damian was kept in the emergency department from the time of his arrival, shortly after midnight, until he was discharged at 2:50am, according to the Lyell McEwin Hospital's medical record. However, the police officers went back to the Salisbury Police Station at 3:20am when material was added. There was a disturbing entry stating that Mr Kay 'was eventually signed off at 2:40am by a doctor who had not spoken with the missing person at that point'.

The young doctor's evidence was that he understood the mental health form to be an acknowledgement of a transfer of custody of the person and nothing more. He signed a form and circled the option 'not detained', which required him to state whether the patient was detained or not detained. In summary, the young doctor had made nine omissions.

1. He failed to request that he be provided with and then read the suicide note that had been written by Mr Kay.

2. He failed to attribute any significance to the fact that, according to the notes which he had available to him that night, Mr Kay had recently ceased antidepressants.

3. He failed to take advantage of the offer of the mental health nurse to accompany him when seeing Mr Kay.

4. He failed to take advantage of the offer of the mental health nurse to see Mr Kay after the doctor had seen him.

5. He failed to take advantage of the offer of the mental health nurse to arrange a follow-up with the Northern ACIS for Mr Kay and gave no thought to that matter himself.

6. He failed to appreciate the significance of the reference to a previous suicide attempt in material that became available afterwards through a psychiatric report received through a fax transmission.

7. He failed to take the opportunity suggested by the mental health nurse that Mr Kay be recalled in consequence of new information that there had been a previous suicide attempt.

8. He failed to attempt to persuade or encourage Mr Kay to remain on a voluntary basis.

9. He failed to seek advice from a more senior staff doctor despite his acknowledgement that these resources were available to him on the night.

In his findings, state Coroner Mark Johns listed those nine omissions made by the young doctor, and he said that the young doctor had failed to attribute any significance to the fact that Mr Kay reported recently having ceased taking antidepressants or the later revelation that he had made a previous suicide attempt. Coroner Johns heard evidence from the mental health expert Dr Andrew Champion, who said that the suicide note demonstrated a high level of implicit intent. Regardless of Mr Kay's subsequent statement, it was Dr Champion's view that Mr Kay's case was evidence of significant suicidal risk and that Dr Champion considered that was grounds to make a detention and treatment order.

Therefore, I call on the Minister for Mental Health and Substance Abuse to adopt the four recommendations in the Coroner's report, and recommend the motion to this council. It is by coincidence that it is a few days prior to the anniversary of when Mr Damian Kay took his own life—on 22 September. I think it is a remembrance time for the Kay family, and I would like to again pay my respects and express my deepest sympathy. It is really hard for me to read out the chain of events because I am sure the family is feeling a lot of pain. I seek leave to conclude my remarks later.

Leave granted; debate adjourned.

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