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Dying in the arms of the state

Richard Baker and Nick McKenzie
September 3, 2011 - 12:00AM


Thirty-six people died unnatural, unexpected or violent deaths in Victoria's mental health facilities between 2008 and 2010. Their deaths drew little, if any, public attention, but each has a story behind it, and a grieving family searching for answers. Today The Saturday Age tells three of those stories - of sick men who died in troubling circumstances in the care of the state.

Died September 8, 2008, at Upton House psychiatric hospital, Box Hill

LUCY Mizzi felt a moment of dread when she hung up the telephone. It was a Sunday night and she had been talking to a nurse at the state-run Upton House psychiatric hospital in Box Hill to check on her little brother, Anthony Travaglini. She wanted to know if his cigarettes had arrived.

But Mizzi never got an answer. ''The nurse suddenly said she had to go because there was a situation,'' she recalls. ''I put down the phone and I said to my husband 'I hope that's not to do with Anthony.' ''

The next morning, a Monday in early September 2008, Mizzi received an unexpected call from a senior psychiatrist from Upton House. He explained that there had been a problem with her brother overnight and asked her to come in to Upton House immediately. Mizzi asked what the problem was but the psychiatrist said he was reluctant to discuss it over the phone. But Mizzi pressed and, after a pause, the psychiatrist told her he had some terrible news. ''I am sorry to tell you this, but Anthony is dead,'' he said.

When he died, Travaglini was into his sixth day of treatment for an acute bout of schizophrenia. For some of this time, the 40-year-old butcher had been in a seclusion ward at Upton House, where he had vomited and urinated on the floor. On the last night of his life, Upton House staff noted in a report in Travaglini's medical file that he was delusional, agitated and difficult to control. One staff member thought he might have been worked up about another patient in the high-dependency unit who had been found with a screwdriver and a concealed spoon- two potential weapons. A report from the coroner says two Upton House psychiatrists discussed Travaglini's condition just after midnight, before deciding to give him an injection of 125 milligrams of a powerful tranquilliser known as Acuphase, a drug usually used when sedation is the only way to control a patient's outbursts. It was his fourth Acuphase injection in 12 days.

Under Australian guidelines, a course of Acuphase should not last longer than two weeks or involve more than four injections. The maximum recommended dosage for a course of Acuphase is 400 milligrams. Travaglini had had 375. The doctors gave him the injections without knowing how many other anti-psychotic drugs were already in his system. Upton House records show that the psychiatrist who oversaw the administration of the final Acuphase injection could not find Travaglini's recent medical files before she gave him his fourth dose.

Not long after 1.30am, Upton House records document Travaglini finally falling asleep. Nursing staff wrote that they could hear his snoring. The family, however, are concerned that some of the checks on Travaglini, who had a sleeping disorder, amounted to a torch being shone through the window.

At 6.30am, according to a Victoria Police brief for the coroner, Travaglini was recorded as being asleep and breathing. At 6.40am, he was checked again by staff and found not to be breathing. A frantic attempt to revive him began, but 35 minutes later the former Marcellin College student was declared dead.

When Lucy Mizzi and her daughter Sarah arrived at Upton House later that morning, no one could explain what had happened. Nor would anyone tell them why Upton House staff had taken more than three hours to contact the family after Travaglini was declared dead (although one staff member told Mizzi he had tried to send her a text message earlier that morning).

A short time later, Travaglini's elderly mother, Elena Travaglini, headed to Upton House hoping to see her son's body, having earlier requested to do so. But when she arrived she was told that the dead man had already been taken from the premises. Travaglini's mother and sisters were told it would be days before they could see his medical records. But before leaving Upton House later that morning, Travaglini's niece Sarah Mizzi says she was approached by an Upton House staff member, who seemed upset. ''Nobody could give us a straight answer and then this staff member came up to me to say, 'This is not right … you make sure you follow this through.' ''

Fellow patients in the high-dependency section of Upton House were also disturbed about Travaglini's treatment overnight. One of them, Adam Farrugia, has told The Saturday Age that, more than three years later, he is still troubled by the incident. He says that before Travaglini was given Acuphase for the fourth time, he was pleading with staff not to give him any more drugs.

''Anthony was a bit upset that night. He was yelling at himself but he wasn't causing anyone much trouble,'' Farrugia says. ''As the night went on he was so drugged out they were dragging him like a rag doll.''

Farrugia has a troubled history. He has had a mental illness and was convicted for armed robbery after being released from care at Upton House in 2008. But he insists Anthony's treatment that night was inappropriate and says he is prepared to testify about it before an inquiry.

Farrugia also says he went to Box Hill police station to report his concerns at the way some staff had treated Travaglini before his death. He says the police he spoke to at the time appeared uninterested. Since then, and despite his claim to be a firsthand witness, no efforts have ever been made to get a statement from Farrugia. The police brief prepared for the coroner does not record him as a witness.

Nor does it include the views of two former Eastern Health employees working at Upton House at the time on Travaglini's death. These staff members - who have asked to remain anonymous because they still work in the public health system - recently told The Saturday Age of their concerns about Travaglini's treatment and the facility's interaction with his family.

''He was overmedicated in my opinion. There was a staff meeting held just after Anthony died where senior management basically ensured Anthony's family was given a consistent story and that's why the family was not contacted about his death for three hours,'' one health professional said.

A senior pathologist at the Victorian Institute of Forensic Medicine, Dr Michael Burke, found no injury or natural disease process that would have led to death. ''It would appear reasonable to suggest the combination of medications in Mr Travaglini's blood has led to his death,'' he wrote.

Almost three years after Travaglini's death, his family remains dissatisfied with the responses from Upton House and Eastern Health. Their questions about whether Travaglini was checked properly during his sleep and whether he had been overmedicated will have to wait until a coroner's inquest set for late next year.

Died December 15, 2009, at Monash Medical Centre

JEFF Hartwig is another tragedy of Victoria's mental health system. As with Anthony Travaglini, his death raises more questions than answers.

Instead of answering any of those questions this week, the health service charged with his care, Southern Health, complained to coroner John Olle about The Saturday Age's intention to publish details of Hartwig's death. Olle imposed a suppression order preventing the newspaper from publishing important information.

But the outline that we can print raises doubts about the quality of Hartwig's care in his final days, as well as of security in the centre. It also raises questions about an apparent lack of transparency in the centre's dealings with Hartwig's family and, later, with police.

A 43-year-old with recurring schizophrenia and a history of drug use, Hartwig was admitted as an involuntary patient at P Block - the abbreviated name of Monash Medical Centre's psychiatric ward - on November 11, 2009, according to his sister and legal guardian, Lynda Gunn.

Gunn recalls him behaving strangely and having developed a sudden concern for the British royal family. He had began writing random letters in which he referred to himself becoming a Queen's counsel in the future.

On December 11, one month into his treatment, Gunn received a phone call from Monash to tell her that her brother had been found slumped in a chair in his room, unconscious, covered in vomit and with only the faintest of pulses. He died four days later, without having regained consciousness, when Gunn decided to turn off the machines keeping him alive.

Nearly two years later, Gunn is still fuming about the circumstances that led to her brother's death, as well as her subsequent treatment by Southern Health. She says no one has been able to tell her what happened in the lead-up to Hartwig being found barely alive in his room on that Friday afternoon.

Gunn believes Hartwig was being supplied with illicit drugs, most likely heroin or another type of morphine-based narcotic, by two people from outside the psychiatric ward. His bank statements show he was spending money without leaving the ward.

Gunn says that in the days leading up to her brother's collapse, she was worried about the state of his health. ''I spoke to him on the phone several times that week. He sounded drugged out. I could barely understand what he was saying. I said to my husband 'He doesn't sound right','' Gunn told The Saturday Age in an interview in May.

Early in the afternoon of December 11, Gunn received a telephone call to inform her that her brother had lost consciousness.

Since that phone call, the Monash Medical Centre has, according to Gunn, been unable or unwilling to provide any information to her about Hartwig's visitors. But she says that no visitors' log was ever kept at P Block and that the hospital's most seriously mentally ill patients were receiving unsupervised visits.

Police sources have told The Saturday Age that the officers investigating Hartwig's death also found it difficult to get answers from hospital staff about the circumstances of Hartwig's collapse. This was, the sources said, because the hospital's legal department had advised staff not to talk directly to investigating officers.

Gunn says she is still stunned by the hospital's apparent failure to maintain visitor records or better supervise those who called in to see her brother. ''They obviously had concerns about visitors but they still allowed this to happen,'' she told The Saturday Age. ''When I think back now, what really gets me angry is that staff said to me, 'You are not going to give him any drugs are you?' a number of times in his final month. I am his sister and I have been visiting him for 26 years in and out of the mental health system.''

Despite the hospital's lack of visitor records, Gunn has determined through her own inquiries that her brother was almost certainly visited by a friend called Steve*, and a woman known to him, in the 48 hours before he was found unconscious.

She knows this because shortly before his collapse her brother had signed a bank withdrawal form that was used - probably by Steve - to take out more than $500 from his account. Gunn believes that after taking the money out, Steve returned to P Block, walked straight past reception and shared illicit drugs with Hartwig.

Gunn remembers the first phone call she received on December 11 from Monash Medical Centre. ''I was horrified … they initially said Jeff was in a coma and I had to come quickly to intensive care. While I was in my car driving there I got another phone call. This time they told me he had died and I was to go to the morgue. I had to pull over and get out of the car and take a minute to get myself together. Then they called me back to say he was still alive.''

When Gunn got to the intensive care unit, she was distraught. Her brother was being kept alive by machines. Hospital staff explained he had probably been given a toxic overdose of drugs in his room in the psychiatric ward.

Back at P Block, Hartwig's room was being emptied and cleaned, even though he was not yet dead. Gunn says she had not been at her brother's bedside an hour when six plastic garbage bags containing his belongings arrived, which she then had to move to her car.

Aside from the lack of sensitivity displayed, the effect of clearing up Hartwig's possessions and cleaning his room was to compromise a potential crime scene in advance of the investigation that began after Hartwig's life support was switched off on December 15. The garbage bags of belongings and clothes were useless to police or any other investigators. Their quick removal from P Block meant they could not be relied upon in any inquiry, as evidence could have been removed or contaminated.

This only threw into relief the hospital's subsequent treatment of gifts that Hartwig's then 10-year-old son brought in while his father was dying. Before Gunn gave the go-ahead for the machines to be turned off, she had made sure the boy, who is now 12, came in to give his father his Christmas presents and to say goodbye. Gunn, who has looked after her nephew (whose mother also has substance abuse issues) since his birth, was shocked when police later confiscated the child's presents, saying they might be required for a follow-up inquiry.

In fact, staff at P Block appear not to have given Gunn everything they found in Hartwig's room. Police sources have confirmed that drug paraphernalia was handed to investigating officers. Gunn says staff in the Monash intensive care unit told her Hartwig's blood showed he had a hefty cocktail of anti-psychotic and other drugs in his system when he collapsed. She wants to know if his medical file accurately records all the drugs he had been prescribed.

The coroner's suppression order prevents The Saturday Age from publishing the findings of a leading pathologist from the Victorian Institute of Forensic Medicine on the causes of Hartwig's death.

Like Anthony Travaglini's family, Gunn will have to wait for a coronial inquest to get any answers about the causes and circumstances of her brother's death.

Meanwhile, she wants the Victorian government to make it mandatory for all visits to psychiatric patients in high-dependency units to be supervised, and for a log to be kept of all visitors. She has suggested the creation of special visitors rooms, which could be monitored by closed-circuit television, to allow family members to visit loved ones without having to confront other patients. She says no one from Southern Health has contacted her since her brother's death to see how she is going.

Died April 20, 2007, at Dandenong Hospital psychiatric unit

ADAM White had been a patient at Dandenong Hospital's Banksia psychiatric ward for just two days. The schizo-affective disorder that had plagued him periodically since the mid-1990s had once again taken grip in April 2007. White, 31, knew he was sick and so did his family. On April 17 he went to Maroondah Hospital voluntarily to seek treatment in its psychiatric ward. It was a significant step as it was the first time he had voluntarily sought care for his illness, but he was, at least, familiar with Maroondah's psychiatric ward, where had been cared for in the past, and which was close to where many of his family lived.

On this occasion, however, he was told no beds were available. After waiting hours in Maroondah's emergency ward, White was transferred by ambulance to Dandenong's Banksia ward. About 11pm on April 19 he was observed by hospital staff pacing in the courtyard. Although he showed signs of being agitated and psychotic, he was given no medication and was eventually settled back in bed.

He woke again hours later and approached the nursing station. This time, he was noted by staff as singing in an odd way and acting strangely.

It was at about this point, say family members, that a situation that might have been defused, instead escalated.

In fact, one nurse did offer him a cup of tea to try and help him settle, before another told him he could not eat or drink as he was fasting for a blood test. According to his sister, Julie Nestic, White protested and asked to have his blood taken straight away, so that he could get something to eat. To defuse the situation, a nurse said she would take his blood, and called security staff to escort him to the treatment room. But there was another hold-up, as the nurse did not have the proper paperwork.

So White was left to sit in the treatment room with hospital security staff watching him from outside the room. When the nurse came back, she announced that it had been decided that his blood would not be taken after all.

White was tired and hungry and ill. He reacted by pulling out a drawer from a cabinet next to where he was sitting and letting it fall to the floor.

It was now about 4am and the three nurses and two security guards on duty overnight had to prepare to unlock the hospital for the start of a new day and the arrival of a fresh shift. In his agitated state, Adam presented a problem. Staff decided to put him temporarily in the seclusion room.

There are conflicting statements from staff about whether White was going to be locked in the seclusion room. Some staff are understood to have made statements claiming Adam was to have been left in ''open seclusion'', meaning the door would have been left unlocked and he would have had access to an external toilet. However, a nurse has said she was bringing toilet paper, a bed pan and water to the room, which suggests the door was to be locked.

In any event, on his way to the seclusion room, White asked for his toothbrush - and was told no. At this point, it seems that the frustration and confusion of the previous hours spilled over. White reacted strongly to being told he could not brush his teeth and a struggle broke out between him and the two male security guards. White, described by his family as a big man, was held in a prone position on the floor. The nurse was elsewhere. When she returned it was too late.

Julie Nestic, who has attended this year's coronial inquest into his death, says it has been stated that during the struggle, her brother yelled out ''I give up'', to no avail, before going still. Nestic says one of the security guards reportedly asked the other, ''Is he playing possum?'' He was not.

White had died of asphyxiation after being held in a position in which he could not properly breathe.

White's oldest sister, Tracey Downward, 43, was preparing her young children for school when she learned that her brother was dead. She remembered the last time she had seen him at Maroondah Hospital's emergency department a few days earlier. She had wiped his face with a face washer and told him she loved him.

With Julie Nestic, she joined other family members at their parents' house and arranged to go to Dandenong Hospital together to view his body. The hospital knew they were coming and a staff member called one of the family on the way to ask them to delay their arrival as the police still had work to do. When they arrived, the family were led into a room where they were told the body had already been taken to the morgue. If they wanted to see him, they would have to go there.

The grieving family was appalled.

''I went off my head asking, 'Why? And, What happened?' '' Downward recalls, ''and the nurse replied, 'Yell at me, that's OK, it's my job.'

''Nine family members had driven from Vermont to see my brother and that's what we got. I have never had any contact from the hospital at all, and neither has my family.''

The lack of information has gnawed away at the family for four years. They only began to get some answers when coroner Peter White began an inquest earlier this year into White's death and that of Peninsula Health psychiatric patient Justin Fraser, who died in similar circumstances at Frankston Hospital in 2007.

White's family has found the coronial inquest interesting and challenging. Told that legal representation would be expensive and unnecessary, they selected one family member to ask the questions that various family members wanted answered. But although the family representative did well for someone with no courtroom experience, Nestic wishes that some form of legal assistance were available to families taking part in the coronial inquest process.

Several of the questions they put to hospital staff were objected to by Southern Health's professional legal team. ''I wished at every moment during the proceedings we could have had a legal person allocated to help us through this time; just to sit down with us and explain the legalities of the proceedings and to articulate our many questions,'' she says now.

From the testimony provided at the inquest, Nestic believes her brother might still be alive had staff tried harder to calm him down on the morning of April 20. Even when the struggle with the security staff began, she says, there could have been a very different ending had a nurse trained in observing restraint procedures been present, as stipulated by hospital policy.

''The signs and symptoms of restraint asphyxia could have been observed,'' Mrs Nestic says.

''There have been so many areas from my brother's death that indicate problems within the mental health system: training the staff; nurse-to-patient ratios; having a code of conduct when approaching patients with a mental illness; early intervention in de-escalation; and the use of commonsense in dealing with grieving families.''

Coroner White is due to give his findings on Adam White's death soon. He may provide more answers for the family. He may also make recommendations to improve the standards of care for Victoria's mentally ill.

But nothing will bring back White, or the 1000 other mentally ill Victorians who have died suspicious or unnatural deaths in the state's mental health system since 2006.

''It's time to wake up and fix this system before it's your family member that needs support or help,'' Downward says.

''I miss my brother every day … I don't think I'll ever get over the way in which he died. I feel we failed him in some way.''

* Steve is not his real name.

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