An inquest into the death of an Aboriginal man in north-west Victoria has found his human rights were breached while he was being treated in hospital the day before he took his own life.
WARNING: Aboriginal and Torres Strait Islander readers are advised that the following story contains the name and image of a person who has died. It also contains details that will be distressing to some readers.
Yorta Yorta man Mathew Luttrell, 43, was admitted to Mildura Base Hospital as a voluntary patient after a suicide attempt on 11 November 2018.
Medical records presented during an inquest into his death described him as "difficult to engage, uncooperative, angry and frustrated, with helpless and hopeless themes".
When he became further agitated after being told he could not eat lunch alone in his room, he was taken to seclusion, or solitary confinement, where he was restrained for two minutes and treated with drugs.
Mr Luttrell was discharged on November 12 and went to stay with his son.
Two hours later he took his own life.
Human rights breached
Coroner Audrey Jamieson found Mr Luttrell's human rights were "demonstrably and unjustifiably breached a number of times" during his in-patient stay at the hospital.
Ms Jamieson found the decision to deploy restrictive interventions was not consistent with the relevant requirements of Victorian law.
"I direct the hospital to report this unauthorised period of seclusion to the chief psychiatrist, in compliance with the Mental Health Act 2014 (Vic)," she wrote in her findings.
Ms Jamieson found the hospital failed to provide Mr Luttrell culturally-specific care and treatment, and also failed to provide culturally-specific follow-up options or support for his discharge.
"This led to decisions about his medical care, treatment and management, being made on incomplete and inaccurate information," she said.
"I find that the notation … that [Mr Luttrell] ‘should not be readmitted to hospital due to the unacceptable risks posed to patients and staff' … along with the options presented to Mathew at discharge, constituted a breach of his human rights, including to the highest attainable standard of healthcare."
Ms Jamieson recommended cultural awareness training be rolled out to staff at the hospital as a matter of priority and that clinicians undertake mandatory training to identify and treat borderline personality disorder.
Death was preventable
Ms Jamieson said she had considered whether Mr Luttrell's death could have been prevented if the hospital had been more responsive to him as an Aboriginal man.
"I have determined that Mathew’s suicide was indeed preventable, given his clinical presentation and mode of discharge the afternoon prior, though cannot say it was preventable in perpetuity given his longstanding mental ill health and chronic suicidality," she found.
"There were the many opportunities missed to intervene in the course of events immediately preceding his passing."
Ms Jamieson noted the Mildura region had a disproportionate rate of suicidality and self-harm among its First Nations communities.
Statistics from the Victorian Suicide Register show Mildura had the highest average annual suicide rate per 100,000 residents between 2010 and 2019, with a rate of 35.5 suicides per 100,000 Mildura residents.
"I consider the following recommendations to constitute a critical step in addressing the specific systemic issues that arose in relation to Mathew’s passing," Ms Jamieson said.
