The coroner’s report on the death of the 20-year-old calls for the establishment of a new mental health unit in Kalgoorlie

A forensic doctor in Western Australia has recommended that a new mental health unit be built “as soon as possible” in Kalgoorlie after discovering several failures at the existing facility.

An investigation into the death of Jordan James Williams has revealed a shortage of safe staff, beds, facilities and infrastructure at the mental health unit at the Kalgoorlie Health Campus.

Coroner Michael Jenkin also urged the Washington State Country Health Service to expedite plans for a new purpose-built facility, and take immediate steps to secure a fence around the existing unit.

There are open sections of the fence in the unit and two patients died at a nearby railway.

Kalgoorlie Hospital is a training ground for many Western Australian doctors.
There were only six families in the mental health unit at the Kalgoorlie Health Campus. (ABC Goldfields-Esperance: Nathan Morris)

The 20-year-old, whose smile “just lit up the whole room”, had been suffering from 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 about his safety.

Chaotic events before death

Mr. Williams was initially cared for in the surgery ward, due to a lack of staff and beds in the mental health unit.

An investigation by the Mental Health Advocacy Service at Kalgoorlie Hospital found that 80 per cent of mental health admissions to the hospital were cared for in wards other than the mental health unit due to a lack of beds.

The Mental Health Defense Service’s investigation also found that security guards were employed in 95 percent of cases requiring individual mental health nursing care.

While in the unit, Jordan Williams made several attempts to escape and harm himself.

During one of the attempts, he was found at the railroad tracks, but neither the nurses nor his psychiatrist were informed of this information.

The coroner said there was a misunderstanding among the staff at the unit, which was facing an acute shortage of staff at the time.

Jenkin said Mr. Williams should not have been allowed to leave his room after his first escape.

An aerial view of a gold mine and the city of Kalgoorlie Boulder, taken by a drone.
Kalgoorlie Boulder, located in Western Australia’s Gold Fields, is home to nearly 30,000 people. (ABC News: Tom Edwards )

Mr. Williams was allowed into the yard again, and he and the security guard assigned to monitor him began kicking a soccer ball with other patients.

After kicking the goalkeeper, Mr. Williams climbed the fence and ran away again.

Around 7:40 p.m. that day, he was found dead after an inspection.

The current unit is poorly resourced

The coroner heard that the resources and facilities in the mental health unit were very poor, and the former record staff refused to return.

Dr. Adam Brett said that some of his colleagues who have held positions as a local psychiatrist in [Kalgoorlie Health Campus] I vowed not to return because the conditions were very bad.”

Nurse Carly Retimana Te Wattu said she did not want her family to be treated there.

The outside of the hospital building.
Jordan Williams survived the mental health unit at Kalgoorlie Hospital and was found dead after a search.(ABC Goldfields: Al-Jaafari City)

The coroner said that while he was satisfied that the standard of treatment and care provided to Williams was appropriate, the standard of supervision he received was “manifestly suboptimal”.

He called on the Western Australian Department of Health to speed up proposals for a new facility, and undertake planning so that it would be staffed appropriately when it opened.

The health service accepts all results

WA’s Qatar Department of Health issued a statement to ABC in response to the report.

A man in glasses and a suit stands behind a microphone.
All of the coroner’s recommendations have been taken on board, says WA Country Health Service Goldfields regional director Peter Tredenk. (ABC Goldfields: Jarrod Lucas)

Tedinek said the unit was not currently facing a staff shortage.

“The safety of our staff and patients is our top priority, and I can confirm that the facility is staffed with enough staff to care for patients in the six-bed unit, with individual specialist nurses and additional security options available when needed,” she said.