The inquest into the deaths of Mr Hitchins and Mr Gudge (heard jointly) dealt with the management of environmental hazards which facilitate or enable suicide in mental health inpatient facilities.


On 3 August 2014, Steven Hitchins was an inpatient in the Low Dependency Mental Health Unit at Townsville Hospital when he was found deceased with a plastic bag over his head. Autopsy confirmed he died due to asphyxiation.

On 10 May 2015, Shawn Gudge was an inpatient in the High Dependency Mental Health Unit of Townsville Hospital when he was found unconscious with a ligature made from a bed sheet around his neck, the other end being secured by the closed bedroom door. He was unable to be revived and was declared deceased. Autopsy confirmed he died due to hanging.

The deaths of Mr Gudge and Mr Hitchins were facilitated or enabled by access to the physical means to suicide. The inquest was convened by Coroner Priestly to better understand the circumstances of both of the deaths, to determine if there were any missed opportunities to reduce the risk of inpatient suicide, and to explore what progress had been made in considering and implementing his Honour’s earlier recommendations in relation to a previous suicide of a Mental Health Unit inpatient of Townsville Hospital in 2013: the Inquest into the death of Justin.

Managing Environmental Suicide Hazards in Queensland

In 2005, the report “Achieving Balance: Report of the Queensland Review of Fatal Mental Health Sentinel Events” was published following a review by the Director General of Health into deaths occurring between 2002 and 2003 involving people with a serious mental illness (including 23 inpatient suicides). The report identified a number of systemic issues, including issues associated with visual observations as well as issues associated with environment and means to suicide. The recommendations included the removal of potential means of suicide wherever possible by correcting potential structural factors in all inpatient mental health units and their immediate environment.

By March 2008, Queensland Health had commenced an audit on all inpatient mental health facilities using a Ligature Risk Audit tool obtained from the United Kingdom National Health Service. The intention was that the audit tool be expanded to include potential environmental hazards other than ligature points. Consultation had also commenced regarding the development of an Environmental Design Guide outlining safe fixtures and fittings that could be introduced into mental health facilities.

Coroner Priestly commented that there was an increasing awareness of opportunities to better manage environmental hazards that might be used as the means of inpatient suicide. However there was emerging differences in approach. Queensland Health proceeded with the ligature audits but progress on the broader subject of environmental hazards started to significantly lag behind.

Inquest into the Death of Justin

On 3 May 2009, Justin died due to choking on a bar of soap while he was an inpatient in the Psychiatric Intensive Care Unit at the Townsville Mental Health Unit. His death was ruled a suicide.

The issues addressed in the Inquest into the death of Justin included the need for improved observations and environmental risk management of suicide for mental health patients. The then Clinical Director of the Townsville Mental Health Unit conceded that there was no systematic approach to identification of hazards for means of inpatient suicide.

Coroner Priestly recommended that the State Director of Mental Health develop and implement an environmental risk management system for the identification of hazards and assessment of associated risks for inpatient suicide. His Honour suggested as a starting point the development of checklists to guide staff conducting routine inspections to identify environmental hazards and to take appropriate corrective action.

The leadership team responsible for Mental Health at a State level was unable to identify any action taken to advance that recommendation by the time Mr Hitchins died from asphyxiation from a plastic bag in August 2014.

Ligature Risks

In 2012, Queensland Health published the “Guideline for Managing Ligature Risks in Public Mental Health Services” which applied to all public mental health inpatient facilities. It contained a ligature audit tool to conduct annual ligature environmental audits.

Coroner Priestly identified that the Guideline does not provide any assistance about how to mitigate the risk of doors used as a ligature point (which was the means by which Mr Gudge hanged himself).

When comparing the Queensland Health Guideline with the approach in the United States by the Veterans Affairs National Centre for Patient Safety, Coroner Priestly rated the Guideline as “abysmal”. Further, unlike the approach of Veterans Affairs, there was no evidence to suggest that Queensland Health monitored the statewide implementation and effectiveness of the Guideline.

By the time of Mr Gudge’s death in May 2015, Townsville Mental Health Unit had identified a number of ligature points, including doors, and started to discuss remedial action. However, the risk of hanging from doors was not remediated. Coroner Priestly attributed this failure in part to a lag in developing internal knowledge and experience in the auditing process due to a lack of detailed guidance given in the Guidelines.

The Current Guidelines

By November 2016, Queensland Health had developed two documents to assist Hospital and Health Services operating public mental health inpatient units to recognise, respond to and mitigate against potential suicide hazards:

  • Managing ligature risks in Queensland public mental health alcohol and other drugs inpatient units 2016 (incorporating an audit tool for monitoring ligature risks) (the Ligature Guidelines).
  • Recognising and managing potential environmental hazard risks in Queensland public mental health, alcohol and other drug inpatient units 2016 (incorporating the ‘recognising and managing of potential environmental hazards and facility’ checklist) (the Environmental Hazard Guidelines).

Coroner Priestly noted that it is unclear why two separate approaches for ligature risks and environmental risks were required. Further, the Ligature Guidelines include a risk rating matrix whereas the Environment Hazard Guidelines do not. Coroner Priestly also was not convinced that the Environment Hazard Guidelines conform to the recommendation in the Inquest into the death of Justin to develop a checklist to guide staff to conduct routine inspections to identify hazards, and take appropriate corrective action.

Decentralisation of the Public Health System in Queensland

Coroner Priestly identified that there is potential for a situation whereby lessons learned from one Hospital and Health Service operating a public mental health inpatient unit are not considered centrally by the Office of the Chief Psychiatrist and disseminated to other Hospital and Health Services with follow up for compliance.

Coroner Priestly attributed this to the restructure in Queensland Health in 2012 (and the passage of the Hospital and Health Boards Act 2012) resulting in some loss of centralised oversight and devolution of responsibility to Health Services for reviewing inquest recommendations, findings of Root Cause Analyses and critical incidents.

The Office of the Chief Psychiatrist has agreed to take part in a quality assurance committee and the Queensland Government has guaranteed that the committee will be established. Coroner Priestly noted that this may be one forum in which to discuss lessons learned from critical incidents, in particular serious critical incidents involving injuries and deaths.

Coroner’s Recommendations

Coroner Priestly made the following two recommendations as a result of the Inquest:

  1. Queensland Mental Health centralise within the State a body, with oversight from the Office of Chief Psychiatrist, tasked with the function of reviewing the findings into the deaths of Mr Hitchins and Mr Gudge, and reporting to Hospital and Health Services on lessons learnt and other opportunities for improvement through internal and external investigations (including Root Cause Analysis reports, Health Service Investigation Reports, Health Ombudsman Reports, Coronial findings and recommendations) as well as like reports from other States.
  2. The Office of the Chief Psychiatrist commission an independent, external audit and review of the extent to which each relevant Hospital and Health Service has implemented the Ligature and Environmental Guidelines as well as the effectiveness of that implementation. The results of that audit and review are to be shared with each Hospital and Health Service as well as any opportunities for improvement.