A West Australian coroner has recommended a new mental health unit be built "as soon as possible" in Kalgoorlie after finding a multitude of failings at the existing facility.
An inquest into the death of Jordan James Williams has found a lack of staff, beds, facilities and secure infrastructure at the mental health unit at the Kalgoorlie Health Campus.
Coroner Michael Jenkin also urged the WA Country Health Service to fast-track plans for a new purpose-built facility, and to take immediate steps to secure fencing around the existing unit.
There are open sections of fencing at the unit and two patients have died at a nearby railway line.
The 20-year-old, whose "smile just lit the whole room up," had struggled with psychosis and depression after losing his mother in 2016 and his father in early 2018.
In August 2018, he was admitted to the Kalgoorlie Health Campus following concerns for his welfare.
Chaotic events prior to death
Mr Williams was initially cared for in the surgical ward, due to a lack of staff and beds in the mental health unit.
A Mental Health Advocacy Service inquiry into the Kalgoorlie Hospital found 80 per cent of mental health admissions at the hospital were cared for in wards other than the mental health unit due to the lack of beds.
The Mental Health Advocacy Service inquiry also found security guards were used in 95 per cent of cases where one-on-one mental health nursing care was needed.
While in the unit, Jordan Williams made multiple attempts to escape, and harm himself.
During one attempt, he was found at the railway, but this information was not communicated to nurses or his psychiatrist.
The coroner said there was miscommunication among workers on the unit, which was facing acute staff shortages at the time.
Mr Jenkin said Mr Williams should not have been allowed to leave his room after his first escape.
Mr Williams was permitted to access the courtyard again, and he and the security guard assigned to watch him began kicking a football with other patients.
After kicking the ball to the guard, Mr Williams scaled the fence and escaped again.
About 7:40pm that evening, he was found deceased after a search.
Existing unit poorly resourced
The coroner heard resourcing and facilities at the Mental Health Unit were so poor, previous locum staff had refused to return.
"Dr Adam Brett said some of his colleagues who had undertaken locum psychiatrist positions at [Kalgoorlie Health Campus] had vowed never to return because conditions were so poor," the report said.
Nurse Karly Retimana Te Whatu said she would not want her own family members treated there.
The coroner said while he was satisfied the standard of treatment and care provided to Mr Williams was appropriate, the standard of supervision he received was "demonstrably sub-optimal".
He called on the WA Country Health Service to expedite proposals for a new facility, and undertake planning so that when it is opened it is adequately staffed.
Health service accepts all findings
The WA Country Health Service issued a statement to the ABC in response to the report.
Mr Tedinnick said the unit was not presently facing staff shortages.
"The safety of our staff and patients is our highest priority and I can confirm the facility is adequately staffed to care for patients in the six-bed unit, with one-to-one nurse specialists and additional security options available when required," he said.
