Citizens Commission on Human Rights

The Mental Health Watchdog

Australian National Office

Vic Nurses Ignored Instructions: Inquest

Nine MSN, 18 June 2013Grave Stone on Sunny Day with ShadowsNurses caring for a Victorian man who hanged himself in a psychiatric facility did not follow doctors’ instructions and made misleading nursing entries, a coroner has found.

But even without these failings, the death of Paul Allan Skinner may not have been averted, Coroner John Olle said.

Mr Skinner, 29, was admitted to the Goulburn Valley Health psychiatric unit as an involuntary patient in November 2010 following a suicide attempt.

A doctor said he could be cared for in the low dependency unit (LDU) but required him to be under 15-minute observations as his condition could result in “rapid, unforeseen shift from feeling absolutely fine to ‘suicidal'”.

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