The man who died of suspected suicide in a Wellington mental health unit was "jovial and joking" in the moments leading up to his death.
The coronial inquest into the death of Sam Fischer has heard evidence today from several nurses who worked with him closely and were on shift the day he died.
He had been "confused" in the morning, a nurse of 21 years whose name is suppressed, said. He’d returned from a meeting with a budgeting advisor about a credit card debt he had mounted of $20,000.
He had banged his head against a wall in the bathroom, but the nurse did not consider that behaviour unusual for Mr Fischer and said it did not warrant an increase in observation of the patient.
It’s not clear whether the bathroom incident was passed on to the nurse who came on shift at 3pm that afternoon, whose name is also suppressed, as it wasn’t in the clinical handover notes and she does not remember if it was included in the verbal handover.
Several anti-anxiety medications were administered to Mr Fischer throughout the day, and his mood improved, but it was low enough for the late nurse to spend extended one-on-one time with him.
They discussed a range of matters, including Mr Fischer being tired and in low spirits and about how they might make him happier on the ward. They went through a bag of gifts he’d received from friends, including cards, and after a while his mood improved.
The nurse said they agreed Propranolol would help and she returned with the medication to find Mr Fischer "jovial" and joking that she should throw it and he would catch it in his mouth.
At around 5:20pm Mr Fischer said he would like to play his guitar, and the nurse said he should come out to the community room to socialise with the other patients and to have dinner.
She had no concerns about him self-harming and said she would be back to check on him at 6pm.
It was at that time that an alarm sounded in the ward. The nurse had to wait a few minutes to be relieved from her post before rushing to find Mr Fischer without a pulse. She took over CPR until he was able to be rushed to the intensive care unit at Wellington Hospital.
She said her hands shook and she was in a state of shock as she filled in the incident report form.
She concedes she made mistakes and wrote down the wrong month when entering the date and missed out other details that should have been on the form, such as when he made certain comments or actions that day.
But both nurses say none of Mr Fischer’s behaviour indicated to them that he would die that night.
Letizea Ord, the lawyer for Mr Fischer’s mother, Lyn Copland, told the court nurses should’ve known his history of self-harm behaviour and increased the number of observations, or times he was checked on that day.
She said his behaviour in the morning, of banging his head against the wall, was a clear sign he was distressed, and it was negligent that this wasn’t written in the clinical notes upon handover.
A recent report by the Health and Disability Commission found failures in the documentation of Fischer’s mental health and the risks he posed to himself, right throughout his time in the care of the Capital and Coast District Health Board.
The report raises concerns that a lack of clear notes could’ve compromised Mr Fischer’s care.
A previous review by the DHB into Mr Fischer’s death in 2015 saw changes made to the way notes are taken and kept, to a digital system, ensuring a patient’s details are centralised and accessible to those responsible for their care.
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