• The nurses were found guilty by a civil and administrative tribunal. (Credit: AAP Image/Moodboard)Source: Credit: AAP Image/Moodboard
The Health Care Complaints Commission revoked the nurses official registrations after they failed to check the vulnerable man's ward.
Dan Butler

12 May 2021 - 1:35 PM  UPDATED 12 May 2021 - 1:36 PM

TRIGGER WARNING: This article discusses suicide

A tribunal has found four nurses guilty of professional misconduct, after an Indigenous man they were supposed to be observing took his own life in 2017. 

The body of the 49-year-old father was discovered in the morning of May 27. He had been admitted to an acute mental health ward several days previously, and was placed under level 3 observation, meaning nurses were required to check on him every half an hour. 

The tribunal found that the nurses recorded the patient as "settled" or "sleeping" in their shift reports, but had not actually checked on the man. 

A blind looking into the man's room was known to be faulty amongst staff, and observation was only possible by entering the room. 

Nurse Jill Louise Watkins, who was responsible for Patient A on the night of his death, was found to have "demonstrated a blatant disregard for patient safety" when she failed to check on him. 

Ms Watkins recorded the man "sleeping" multiple times before he was found. 

Nurses Emma Kate Brown, Mehul Mukundray Dudhela and Florence Egbufor were also found guilty by the tribunal. 

The man, dubbed Patient A during the investigation, had a history of mental illness, and had attempted to take his own life several times in early 2017. 

The following May, after expressing feelings of "suicidal ideation" to his GP, he presented himself to the Sydney hospital in question. 

Patient A was living out of his car at the time after having broken up with his partner, and reported worsening depression due to an inability to contact his adult children. 

This history was known to the shift nurses on the night of Patient A's death, as well as his designation as an Observation Level 3. 

The man was found at 7:30 in the morning. A coroner's report found that the man had died between two and eight hours earlier. 

While two of the nurses had subsequently stopped practicing nursing, the other two had their ongoing registrations officially revoked by the tribunal. 

The complaint against a fifth nurse who was also investigated by the Health Care Complaints Commission was dismissed. 

Crisis support is available from Lifeline on 13 11 14.

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