Coroner's Court of Western Australia

Inquest into the Death of Devan Beau GINBEY

Inquest into the Death of Devan Beau GINBEY

Delivered on :  6 May 2024

Delivered at : Perth

Finding of : Deputy State Coroner Linton

Recommendations :

I recommend that the Minister for Health commit to funding SMHS to build a 10 bed Mental Health Observation Area and 20 bed Inpatient Mental Health Unit when SMHS take over the operation of Peel Health Campus at the end of 2024.

Orders/Rules : N/A

Suppression Order : N/A

Summary : Devan Ginbey (Devan) hanged himself on the morning of 13 January 2023. He suffered an irreversible hypoxic brain injury as a result, and died on 16 January 2023. A discretionary inquest was held into Devan’s death on 2 and 3 November 2023 as he had been waiting for a long period in the Peel Health Campus ED, waiting for a mental health bed, immediately prior to his death. Devan had left the ED at 6.30 am without being observed by the ED staff and was found hanging at home before police were notified of his absence.

Devan was a young man who had experienced some significant challenges in his life, including the suicide of his best friend and an episode of psychosis precipitated by prescribed ADHD medication. On 12 January 2023, he self-harmed by cutting his arms. He was taken by his mother to Peel Health Campus for medical treatment. Devan told the triage nurse on presentation that he wanted to see a psychiatrist. After his cuts were treated, Devan was reviewed by a Psychiatric Liaison Nurse (PLN). Devan appeared to be exhibiting signs of psychosis, including possibly experiencing auditory hallucinations. Devan made it clear he was frightened that he might harm himself again and he wanted to be admitted for psychiatric treatment. He agreed to a voluntary admission at any mental health unit that had a bed available. The PLN completed the relevant referral for Devan to be allocated a mental health bed, either at Rockingham General Hospital, which was the closest hospital, or elsewhere.

While Devan waited for a mental health bed to become available, he was allocated a bed in the Peel ED. The bed he was allocated was in the centre of the ED, next to the staff ‘Flight Deck’. The bed was one of four patient overflow beds placed around the Flight Deck, and there was evidence the beds were commonly allocated to mental health patients as they did not require physical medical monitoring (given the beds did not have any equipment near them) and they were highly visible to staff, which was considered helpful to allow staff to monitor these patients.

Devan remained in his allocated Flight Deck bed overnight. He was reported to generally be calm and appeared to be sleeping. His last interaction with a Peel ED staff member was at 6.04 am, when he was assessed for any signs of alcohol withdrawal. At 6.21 am, the nurse shift coordinator sent a follow up email, still seeking a bed for Devan. Devan seemed calm and settled at that time. About 10 minutes later, Devan got up and walked out of the ED through the open ambulance access doors. His absence was not initially noticed by the ED staff as they were preoccupied by an agitated patient who required sedation. This patient was in a bed near to Devan’s, and their disruptive behaviour appears to have disturbed Devan.

Devan’s absence was noted at about 7.30 am and security staff were asked to look for him. Devan’s mother returned to the ED not long after. She noticed his belongings were still on his bed and asked a nurse where he had gone. Devan’s mother and the nurse began to look for Devan in other parts of the hospital and outside, but they could not find him. Devan’s mother thought it was possible he had gone for a walk to get a break from the noisy ED. When she left, she was told the staff would keep looking for Devan and let her know when he returned.

Later enquiries established that after Devan had left the ED, he walked down the hospital driveway and left the premises. When he had not returned to the hospital by 9.00 am, the PLN who had assessed Devan the previous day rang his mother to discuss what they should do next. The PLN discussed with Devan’s mother the possibility of notifying the police, but Devan’s mother was concerned that this would cause Devan further agitation and make him more reluctant to seek help. They agreed to wait a bit longer for Devan to return. Sadly, around the same time, Devan’s grandfather had gone to Devan’s house to do some jobs and found Devan hanging in the garage. He cut Devan down and performed CPR until police and ambulance officers arrived and took over resuscitation efforts. Devan was taken to hospital but he had suffered a severe brain injury and his prognosis was very poor. He died a few days later.

An internal review of the medical care found that there were issues with bed placement for mental health patients in the ED, as some beds (like Devan’s) were in noisy positions and were too close to the ambulance access doors, noting that the patients often had to wait a long time for a bed due to a systemic lack of beds in the public health system. The panel agreed that there needed to be a documented management plan for voluntary patients to cover whether supervision was required and who should be detained if they tried to leave while these patients waited. At the relevant time, there was no PLN on duty overnight, so it was recommended that they move to 24/7 PLN coverage in the ED, which has now been implemented.

A review by an independent expert, reached the conclusion that Devan’s management was generally appropriate, but agreed that the lack of access to mental health beds leads patients like Devan waiting for long periods in a non-therapeutic environment and without appropriate supervision. The expert recommended consideration be given to creating a Mental Health Observation Area for patients like Devan waiting for a mental health bed.

Evidence was provided at the inquest that Peel Health Campus will transition from a private-public arrangement between Ramsay Health and SMHS to operation solely by SMHS by the end of the year. As part of planning for the future management of the hospital, SMHS is putting up a recommendation to the State Government for funding to build a MHOA and a mental health bed unit at PHC. The Deputy State Coroner made a recommendation supporting an allocation of funding for this plan.

The Deputy State Coroner found that the death occurred by way of suicide.

Catch Words : Discretionary Inquest : Suicide : Hanging : Psychiatric Treatment : Peel Health


Last updated: 16-May-2024

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