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SA Coroner says death of patient Ross Alcock not fault of nurse who made “concerning” mistake

(John Leopold, RAH psychiatric ward nurse, outside the Coroners Court where he gave evidence at the inquest into the death of Ross Alcock. Picture: Roger Wyman)

A NURSE’S misunderstanding of a hospital’s patient checking system is not responsible for the death of a mentally ill man but is a matter of “considerable concern”, the State Coroner says.

On Thursday, State Coroner Mark Johns said the Royal Adelaide Hospital never explained why one of its staff had made such a basic error, nor assured him it would not be repeated.

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In his findings into Ross Matthew Alcock’s suicide, he said registered nurse Dominic D’Apice had wrongly checked on his patient hourly, instead of half-hourly.

“It is not possible to conclude that Mr Alcock’s death was directly attributable to Mr D’Apice’s incorrect understanding,” he said.

“Half an hour is more than enough time ... to do what Mr Alcock did with fatal consequences.

“However, it is a matter of considerable concern that a matter as important as half-hourly checks was not properly understood by the staff member primarily responsible for carrying them out.

“Furthermore, there was no explanation by any person in a position of responsibility for

how such a state of affairs could have arisen, nor any assurance that it would never

happen again.”

Mr Alcock, 22, of Cairns, took his own life after voluntarily admitting himself to the hospital in February 2014 due to feelings of paranoia and anxiety.

A coronial inquest heard he was found dead, from self-inflicted asphyxiation, in a wardrobe in his room.

In his evidence, Mr D’Apice admitted he wrongly believed his task was to check on Mr Alcock “on the half-hour”, and so did so once every 60 minutes, not every 30 minutes.

Mental health nurse John Leopold also conceded he improperly checked on Mr Alcock, having only seen his legs and torso but not his face while looking into his room. (John Leopold, RAH psychiatric ward nurse, outside the Coroners Court where he gave evidence at the inquest into the death of Ross Alcock)

In his findings, Mr Johns said the ward in which Mr Alcock was housed had visibility and space issues, adding the wardrobe provided “ready access” to those intending self-harm.

“There is a balance to be drawn between benignly observing a patient in a manner that is not too intrusive, and ensuring their safety,” he said.

“However, on a ward with (such) physical disadvantages and shortcomings ... it is very difficult to see how that balance can easily be drawn.

“I have nothing further to add.”

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