‘He tried to save himself’
Coroner: hospital system failed desperate man
JOSEPH Aaron Lattimer tried to reach out before he cut his life short in an emergency department toilet cubicle.
The 37-year-old, found unconscious while awaiting emergency psychiatric treatment at the Royal Hobart Hospital, was failed by the system he reached out to for help.
On Friday, Coroner Olivia McTaggart handed down her findings into the Mornington man’s tragic death, finding a connection between his death and key failings at the hospital.
Her findings followed an inquest in October 2019 that revealed the scope of the Royal Hobart Hospital’s acute staffnurses ing shortage and its ambulance ramping crisis.
Ms McTaggart said in July 2016, Mr Lattimer had taken a “most difficult” step in calling an ambulance, seeking treatment for suicidal ideation “in order to save his own life”.
Upon arrival, he was triaged into an emergency category, requiring treatment within 30 minutes. But due to critical staff and bedding shortages, Mr Lattimer sat in the waiting room for 42 minutes, “alone and without a support person”, before the suicide attempt that led to his death 11 days later.
After Ms McTaggart handed down her findings, Mr Lattimer’s mother, Julie, read out some words her son had written before the tragic episode, detailing the dreams he had for his life. “I want my daughter … to be proud of me. I want to live,” he wrote.
Mr Lattimer, who suffered post-traumatic stress disorder, anxiety and depression, said he dreamt of being able to be well enough to again go bushwalking, surf with his sister and sail with his dad.
He wrote of wanting to work with reptiles and hoped to one day open his own business.
Ms McTaggart said Mr Lattimer
was not placed in a safe environment after he was triaged or given a support person while he waited. “I find that there was a connection between these failures and Mr Lattimer’s death,” she said.
Ms McTaggart said she didn’t criticise any of the staff working in the emergency department at the time, saying they performed their roles diligently and efficiently.
“The issues affecting Mr Lattimer’s situation were caused by insufficient staff to attend to him and insufficient, appropriate space to accommodate him,” she said.
At the inquest, paramedic Andrew Sculthorpe said since Mr Lattimer’s death, ambulance workers were now required to stay with mental health patients until they were admitted – with the “ramping” process sometimes taking hours.
Ms McTaggart recommended the hospital’s emergency department be redesigned to include a dedicated mental health assessment unit, “in accordance with contemporary standards”.
She also recommended the state government take steps to recruit psychiatric emergency along with other healthcare workers who could either triage, assess and treat mental health patients or provide support while they waited for help.
A spokesperson said the government noted Ms McTaggart’s recommendations, saying more was currently spent on mental health services in Tasmania “than ever before”, with an additional $16m in the 2020-21 state budget.
The spokesperson said the hospital currently had more than five full-time-equivalent psychiatric emergency nurses and a six-bed mental health short-stay unit had been established, with staff recruitment currently under way.