(Registered Nurse Domenic D'Apice outside the Coroners Court during the inquest into the death of Ross Matthew Alcock)
A HIGH risk psychiatric ward patient took his own life in an hour-long gap between observations created by a nurse’s misunderstanding of a “poor system”, an inquest has heard.
On Tuesday, State Coroner Mark Johns opened his inquest into the February 2014 death of Ross Matthew Alcock while under psychiatric care at the Royal Adelaide Hospital.
His care was the responsibility of registered nurse Dominic D’Apice, who gave evidence he conducted a check upon Mr Alcock “on the half-hour” during his shift.
He agreed that meant “the reality” was Mr Alcock was only being checked hourly (such as 2.30pm, then 3.30pm, then 4.30pm), not strictly every 30 minutes as required by hospital policy.
“At the time, I didn’t understand that I was primarily responsible for conducting the half-hourly round ... I’ve since now rectified that error in understanding,” he said.
“I believed, wrongly, my responsibility was on the half-hour.”
Mr D’Apice’s evidence failed to impress Mr Johns.
“I just don’t understand what you’re saying, frankly, it doesn’t make sense,” he said.
“It’s a very poor system, isn’t it?”
Mr Alcock, 22, of Cairns, voluntarily admitted himself to the hospital during a sightseeing trip with his mother, Caroline Ross, due to feelings of paranoia and anxiety.
The inquest heard he had considered harming himself during a wine tour prior to his admission, and believed Freemasons were telling him to hurt himself and his family.
On Tuesday, Mr D’Apice, who is now a co-ordinator in a community care facility, told the inquest he had conducted Mr Alcock’s initial assessment.
He rated Mr Alcock’s potential to harm himself as “very high” and later upgraded the risk he posed to others from “very low” to “moderate”.
Following admission, Mr Alcock became one of four patients in the 20-patient ward for whom Mr D’Apice was responsible — but he admitted he had not understood that.
He also admitted he had not signed off on patient check records, saying he had believed his task was to report any observations to his peers for them to sign.
“Observations were to be half-hourly, it was my responsibility to conduct them, but at the time I was under the assumption that all staff were responsible for those checks,” he said.
“I didn’t believe it was my responsibility at the time.”
Mr D’Apice said Mr Alcock had “not engaged” with him in the hours leading up to his death, giving only non-verbal responses and saying “that’s how the world works”.
He said he was in the ward office “tidying” his notes for handover when a fellow nurse said Mr Alcock could not be located.
“We conducted a check to find him, checking the whole ward starting from the room closest to the office,” he said.
“When we entered Mr Alcock’s room, we found him slumped in his wardrobe.”
The inquest into Mr Alcock’s death — by self-inflicted asphyxiation — continues
You can also read, SA Coroner says death of patient Ross Alcock not fault of nurse who made “concerning” mistake (it’s linked to the second post)