Care of patient at Hillmorton Hospital 'woeful'

The care of a mentally ill man in Hillmorton Hospital was "woefully" inadequate on the day he died, his father told a coroner's inquest.

An inquest into the death of Anthony McKeown, 36, began yesterday.

McKeown died in January 2004 while in a locked unit at Hillmorton Hospital.

Letters read to the court from McKeown's father, Tony McKeown, said his son was diagnosed with schizophrenia as a teenager, and his mental state and behaviour had "hit rock bottom" in 2003.

His son was admitted to Hillmorton without the family's knowledge and was then transferred from one unit to another because he was considered a risk to others.

He was not, however, considered a risk to himself, and was put on routine observations, which meant he should be sighted every 15 minutes, Tony McKeown said.

He said staff actions on the day of his son's death "fell woefully short" of providing necessary medical interventions to keep him safe.

His son was also not given an anti-psychotic drug that he was prescribed.

Tony McKeown said his son was known to be suffering paranoid delusions and would have been frightened of being confined, but was left alone in his room for 45 minutes.

When he was discovered in his room, the emergency equipment used to treat him was inadequate.

The oxygen cylinder was empty, the mask did not fit and the suction equipment was fitted wrongly.

He said his son's death was "totally preventable" and someone should be held accountable.

A Health and Disability Commission report released this year found the Canterbury District Health Board breached standards of care for Anthony McKeown.

It found the board "did not have appropriate functioning resuscitation equipment to hand ... or staff adequately trained in emergency response".

The report said doctors had failed to adequately care for Anthony McKeown because some believed he was faking his problems.

The commissioner also criticised the length of the police investigation into the death, which, it said, frustrated the normal accountability processes for health professionals.

At the inquest, Detective Sergeant William McIvor said the investigation took three years because police were working on several homicides.

There were also some delays in getting statements from medical staff.

A doctor and nursing staff had been under investigation, but police decided not to lay criminal charges, he said.

Evidence given by an expert witness at yesterday's inquest has been suppressed. The names of all the medical staff who treated Anthony McKeown had also been suppressed.