Suicide On The Ward

NZPN

I remember Elaine Ngatai so well.

She was one of the patients I had worked with so many times before. She was a truly unhappy woman, but we could never find out exactly why. We knew her marriage had broken up, we knew her neighbors hated her and egged her house among other charming activities - but she wouldn't or couldn't tell us why she wanted to die.

Neither could her family.

Her final admission began on 23rd July 2006.

She was brought in from Accident and Emergency, after sustaining a strained neck in a car accident.

Ms Ngatai admitted flatly that she had lied deliberately to Dr Mahomet, her Psychiatrist, the previous Friday. She had said "all the right things" - I.e. I feel fine, I'll take my medication, I'll be at home when my Community Psychiatric Nurse comes - etcetera - and because of that, Dr Mahomet had to suspend the Mental Health Act, and let her out.

Two days later, she went straight out to a nearby forest park, parked her car, and attempted to gas herself.

After an hour or two, she woke up with the engine still running, gave up in disgust, and drove back into town.

On the way, she passed out from the effects of the carbon monoxide and went straight into a power pole. After all that, she still only had a strained neck and a headache, and to her great disappointment, was very far from dead. After being assessed at Accident and Emergency, she was placed under the Mental Health Act - yet again - and brought to the Intensive Psychiatric Care Unit, a locked ward of the hospital.

Ms Ngatai sat down on the sofa, watched the television with unseeing eyes, and refused to talk to the staff. She accepted a few hot drinks, refused all food, and did minimal activities of daily living. She showered once a day, but she didn't brush her hair, or change her clothes or bedding, unless the staff prompted her to do all three.

It was a cold and rainy mid-Winter, and Ms Ngatai's face looked rather like the weather. Every now and then I caught a glimpse of an abyss of despair... but she wasn't talking - about that, or anything else. She was polite to the staff, but no more. When Dr Mahomet came to see her she wouldn't talk to him either. However, he was a rather rude man, so she didn't talk much to him anyway - and neither did the nurses unless it was necessary.

I completed the admission data, and noted on the forms that Ms Ngatai - as per usual presentation - had recently attempted suicide with a reasonably lethal method, and she was upset that it had not worked.

Ms Ngatai had a long, long, history with the Mental Health Service. She was also an outpatient of the Maori Mental Health Team, who the mainstream team had rather varied reports of - everything from "they are so kind and supportive" to "hell, those witches tell my whanau (family) everything and can't keep anything quiet, I'm going with the Pakehas (white people)!" But whatever she thought of them, Ms Ngatai wouldn't tell the nurses from her own ethnic group anything either. She was also known to be noncompliant with her antidepressants. The days ticked on, with morning and evening shifts saying the same thing.

"Ms Ngatai remains flat in mood with a restricted affect. Poverty of speech apparent. Thoughts of suicide occasionally expressed but not interacting with staff or co-pts. Nil emotion expressed. Insight and judgement impaired. Fluid intake satisfactory but refusing food."

We had re-started her antidepressant medication - yet another different one as she would give up after four to six weeks on one medication, and when re-started on medication again another type would generally have to be offered before she would take it. She reluctantly took it, and we gave her Clonazepam and Zopiclone to assist her to rest and get some sleep. She did get some sleep, the night shift reported, but she was often found sitting awake on the side of her mattress, and refusing offers of any assistance (hot drink, one-to-one talk, extra PRN tranquillisers etc.)

I should explain that the IPCU is a very secure environment - the local constables who came to assist the nurses from time to time, were heard to say it was more secure than the cells down at the Police Station (!)

The toilets and showers are similar to prison ones so nothing can be hidden in them, or under them, and the patients have only a mattress, quilt, thick sheet, and pillow in their rooms. To try and make it a bit less jail-like there are paintings done by the patients screwed to the walls but that has rather limited success. At that time, due to the present Psychiatric Unit once being a Psychogeriatric one, there were thick handrails in all of the showers. The Unit Manager requested Engineering to take these away three times, beginning in the March of 2006, with no reply.

The Wednesday shift began the same as usual. Ms Ngatai was flat and noncommunicative. The other three patients were leading a bit of life to the proceedings. Marie Campbell was shrieking about dead cats while dancing about in pink pyjamas covered with cute little pussycats. Kathryn Jones was coming right but still completely lost in her own thoughts about summonsing the Indian God Sa-Baba to the Psychiatric Unit by chanting his name nine times, and Mr White's depression was resolving and he was to be transferred to the Open Wards sometime that week.

Jaclyn Adams was on with me (due to her last name, and habit of wearing skulls on caps, socks, and other garments whenever possible - I call her Morticia). We made toast and hot drinks. While everyone else ate, Ms Ngatai accepted a hot chocolate but refused anything else, stating flatly - "I don't eat."

I was also precepting George, a student nurse.

The rest watched television while she stared into space. I was feeling flat too. After a while, Helen Brown appeared to cover dinner breaks. I went off first, and when I returned - feeling flatter still, I sat down on the floor and told Helen how I felt (frustrated in love or something like that, I think). Helen told me she had let Ms Ngatai into the shower, and that all was well on the quarter hour check. We always have someone of the same gender check people showering - particularly with women and Maori patients.

At 19:30 Jaclyn returned and remarked "the check's due isn't it?" And both of them went off to check on Ms Ngatai. I had a horrible feeling which I couldn't explain, and went out after them.

"Elaine!" called Jaclyn. No reply. "Elaine!" She called again. No reply. Helen listened carefully. "That sounds like water just hitting the floor."

I spoke quietly from the rear. "Tell her that if she won't talk to us we will have to come in." Jaclyn did that, no reply, and she opened the viewing window.

"She's hanging!"

In we went. Ms Ngatai was hanging by her hospital pyjama trousers from the thick shower rail. I tried to undo the knot while Jaclyn lifted her up and Helen went for the Hoffman knife - a hooked knife that can cut rope and wire. She handed it to me, and I cut her down.

We began artificial respiration, administered oxygen via a non-rebreather mask at 15L/min, and I got George to ring his alarm to get urgent help from Open Ward. The Crash Team were called at 19:33, and our own crash trolley was brought in. We tried to insert an oropharyngeal airway, and started bagging. Ms Ngatai was blue and unresponsive. We set up the AED and connected it to Ms Ngatai - and remembered just in time that she was lying in a pool of water, and we would all be shocked as well. So we had to leave that as it was, and stick to manual CPR.

The ICU Registrar arrived with as many nurses in tow that could be spared from there. They inserted an IV, took out the airway that the Psychiatric Nurses had put in the wrong way, and intubated her. They called the Anaesthetic Registrar in as well. We all ran around drawing up IV flushes and getting extra oxygen cylinders for them. They got an unsteady rhythm, but then she aspirated, vomited, and there was no going back after that. Life support ceased at 20:04.

While the others cleaned Ms Ngatai up and put her in a clean gown, I made yet more hot drinks and tried to calm down Ms Campbell who was going on about cats again, and who was the only patient in this world enough to have some idea of what was going on. She wanted to see Ms Ngatai's body but thankfully she was unanimously declined.

The mortuary trolley was sneaked around the back of the hospital so the patients in the Open Wards wouldn't see it. I helped the other staff lift Ms Ngatai in, and watched the orderlies wheel her away. We called in the Charge Nurse who secured the scene, notified the Unit Manager, and rang up the Police.

Only brief statements were taken at that time, and one of the Constables told me off for cutting through the knot and destroying evidence. I think I said drily that the cause of death was beyond doubt. Everyone else was very kind.

A little later, I came across the Unit Manager as we got out blankets for the shocked patients and even more shocked staff. I put my arms around him. He was embarrassed - not being used to being hugged by men - but I was far beyond caring. I laid my head on his chest and listened to his steady heartbeat, feeling the life that pulsed through him and trying to banish death from my mind... I smiled wryly to myself a little later, when I realised that I had been cuddling the Boss in the proverbial linen cupboard!

The following week, the law took over. The medical notes were seized by the Police. A formal statement was taken from everyone except Jaclyn, who had a long planned visit to see her family in the United Kingdom underway, and the Police decided not to interview her. I gave the Police all the details above, and the notes and statements were sent off for a hearing in the Coroner's Court.

The family were quite good about it at the time and said any of the staff who wanted to come to Ms Ngatai's tangihanga (funeral) at the Marae (meeting grounds) were welcome. But we were all too upset to go. We meant to send flowers, but never got round to it. I think some were sent on our behalf by the Psychiatric Unit.

By the end of the year, I was a mess. During the Hospital's own inquiry I had been idiotic enough to say I had no hope for Ms Ngatai - a totally unacceptable thought in today's environment, and that resulted in long meetings with the even more idiotic Nurse Educator to try and make me more hopeful. It was also found that I had forgotten to get my annual practicing certificate, had put the Hospital at risk by practicing without one for six months, and got a temporary written warning on my file until April 2007. I started thinking a nurse I didn't like was following me around and spying on me, and told the Nurse Educator I was going to punch her. I ended up seeing a psychiatrist and being put on a brief course of antipsychotics. I went to see the charge nurse and offered to resign, and to her credit, she was honestly shocked. She told me that I was a credit to the team, she didn't want me to go at the best of times, and she would offer whatever support she could during the interminable wait for the Court Hearing.

We finally got told it was happening six months later, and the hearing opened in the mid March of 2007.

The Police were very good, explained all the proceedings, and read our statements taken the preceeding August out for us, once we had taken the Oath and sat in the witness box.

The Unit Manager was questioned very closely about the shower rails, and he told the Coroner that he had requested something be done about them three times due to the obvious risk, but that nothing was done until Ms Ngatai died - then they were off and out within 24 hours.

Helen and I were both questioned about nurses putting constant observations in place. Helen explained she was covering dinner breaks and that nurses can do it if they see a definite and immediate risk, and was allowed to go.

I explained that we were caring for the patients on a 1:2 ratio, that we documented checks every quarter hour, that we COULD start constant obs at any time, but we needed the Psychiatrist's agreement to carry it on for more than about 12 hours, and that we had to have clear and immediate risk to justify invading the patient's privacy more than we already were. I added that Ms Ngatai had presented the same as before and that although she had clear suicidal behaviour there was no reason to believe, at that time, that an attempt was imminent as she had never attempted suicide in the hospital setting - her many attempts had all been in the community.

Then Dr Mahomet was on the stand, and did he try to paint the nurses black! He said we should have started a constant and got another staff member in, and it was all our fault. Thank heaven, the Coroner talked to him very sternly, and said that the nurses are capable of assessing risk, and all statements received apart from the Doctor's stated that there was no imminent risk of suicide apparent. He also reminded Dr Mahomet that his own reports in the seized medical file stated that there was no imminent risk at that time.

He then ruled that Ms Ngatai had died by her own hand, and stamped the file shut.

The family seemed rather divided. Half of them hugged the nurses, the other half stared at us stonily. My Grandmother and Mum's friend who was there as her stand-in (Mum was off in the U.K. for the birth of my niece), took me off for coffee. Grandma said she could hardly hear a thing, and I said it was probably just as well. Mum's friend said my evidence was clear, and that she really didn't like that doctor...

Two and a half years later, it is still not over. Ms Ngatai's mother laid a complaint against the Hospital with the Health and Disabilities Commission, who - to their great rage - were unable to access either the legal file or the patient notes, as those were both sealed. So we had to do out new statements in early 2007. We have heard nothing further, and perhaps no news is good news.

Unlike other patients who have died, I cannot go and visit Ms Ngatai's grave, as she is buried on her Marae, and Maori from other tribes, and non-Maori cannot go there without permission. I do not think permission would be given, under the circumstances.

That experience changed my life... and mostly not for the better.

But now I can ask who really, is the selfish one, when a suicide occurs - and have some credibility in doing so, once I relate what happened to the staff on that shift. Is it really the patient who is selfish, as some people say - or is it really, that society is selfish - that we want utterly miserable people to stay alive, so we don't have to feel guilty when they die?

I have been told that suicide is a permanent solution to a temporary problem. That is very true - when the problem is temporary. And not all of them are.

Despite what the Mental Health Services do with suicide watches, risk assessments, regular visits, extra medication, extra supports, whatever, the suicide rate is affected far more by economics, wars, and the person's individual circumstances - some unchangeable - that say who will, and who will not, die this way.

Sometimes, I wonder if I will ever forgive that woman for killing herself on my shift. Sometimes I felt it would be preferable to take all the pills I had in the house, rather than return to work. We weren't allowed any time off - the Manager and the Charge Nurses were sure we would brood on it more than ever and never return to work if we did that - and in hindsight they were probably right.

I still enjoy being a Psychiatric Nurse, but I've never been the same since. Weirdly, what helped me most was a trip to Africa last October, where I saw people living on $1 a day or less, all sorts of disabilities with no assistance, and I had to step over open sewers to pick my way down the street. And when I realized that even if I had been fired and packed off to a state house on the benefit - I would still be much better off than most people in the world, the grip that work and the future orientated Western outlook had fell away. I love being a nurse - but if I lost my career, as I was in considerable danger of at that time - the world would not end, as it would for some, and I would still be alive - and kicking.

*** All names in this story have been changed ***

Suicide On The Ward

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