Aboriginal and Torres Strait Islander readers are advised that this article contains the name of a deceased Aboriginal person. Readers are warned there may be words and descriptions which may be culturally distressing.
An Aboriginal man who took his own life in Victoria in 2022 received "suboptimal" medical care from a regional hospital in the lead up to his death.
William Thomas Gourley, a proud Aboriginal and Torres Strait Islander man on his mother's side who lived in Moe on Gunaikurnai Country, was 39 years old when he died as a result of self-immolation in his bedroom on March 6, 2022.
He had left Latrobe Regional Hospital (LRH ED) earlier, having not had a mental health check in the two hours he was present, despite experiencing feelings of delusion.
Mr Gourley had experienced a number of mental health issues over this lifetime.
Furthermore, he had experiences of sexual assault, and reported delusions that people were attempting to harm him, as well as expressing his suicidality.
On the night of March 6, having left the hospital and leaving the house for several hours before returning, his mother, Suzanne Gourley, and her partner David Gourley, heard a fire alarm and witnessed smoke coming from Mr Gourley's door.
Despite attempting to enter, he had blocked their entry, replying, "don't open it, go away".
When they did, they observed Mr Gourley alight, before he barricaded himself in his bathroom.
At 12:11am on March 7, he was declared as having passed away after paramedics had performed CPR.
Coroner Audrey Jamieson said the treatment of Mr Gourley at LRH was "suboptimal".
"I find that there was an unfortunate chain of events set in motion upon his arrival, when he received a cursory review at triage such that key information regarding his acute mental ill health and level of risk was not properly considered," she said.
"...upon learning of William Thomas Gourley's departure from the emergency department, Latrobe Regional Health staff's actions fell short of those expected from them".
Coroner Jamieson heard a day before his triage, Mr Gourley informed his mother, "that he was going to set his room on fire".
Mr Gourley checked in to LRH ED on March 6 after telling a GP he was experiencing "low mood and suicidal thoughts", as well as divulging delusions that people were attempting to poison him.
After driving himself to LRH ED with "paranoia and fluctuating auditory hallucinations, and reported marijuana use the day before," Mr Gourley was triaged at 3:41pm as a 'Category 4' (to require treatment within the hour) and was referred to Mental Health Triage.
A nurse noted he had been referred by a GP but didn't consider the details of the letter written by Mr Gourley's doctor.
Furthermore, the coroner noted it was unclear if the staff were aware he was Aboriginal.
LRH stated: "[William's] Aboriginality would not have changed the treatment he received in the ED."
However, they also noted that "if he had been admitted…his Aboriginality would have prompted and necessitated he be seen by the Aboriginal Liaison Team within a few hours".
In response, Coroner Jamieson said: "I have considered the LRH response and note it does not acknowledge that Aboriginal and Torres Strait Islander people suicide at a disproportionate rate in comparison to their non-Indigenous counterparts."
"While an appreciation of William's Aboriginality may indeed not have impacted the treatment, he received at the LRH ED…it remains that he belonged to a demographic which experience increased rates of suicides…and that a keen understanding of the intersection of these factors may have led to a re-evaluation of his risk."
Despite appearing "unsettled and fidgety" with "rapid speech and thought process" and expressing that he felt as though he had "two personalities," by the enrolled nurse, the escalation was not expressed to senior staff.
Mr Gourley left the cubicle he was in for a cigarette between 5:30 and 6:00pm - despite previously telling staff he didn't smoke - before leaving the premises.
When he left the unit two hours after being triaged, he had not been given a mental health assessment, despite the requirement of it being done within the hour.
His mother called LRH ED saying Mr Gourley had said he was coming, but the hospital informed her he was a voluntary patient and advised her to contact emergency services if she had further concerns.
"William's departure was not escalated to the Registered Nurse in charge, or to a senior clinician," Coroner Jamieson said.
She said she was "unable to definitively find" Mr Gourley's death "could have been prevented having regard to the preceding chain of events," noting his suicidal iterations, and a history of mental illness.
However, she stated the actions taken by LRH saw "several missed opportunities to re-evaluate William Thomas Gourley's risk and provide him with appropriately prompt medical treatment".
Coroner Jamieson recommended LRH implement a procedure specific to its ED regarding a patient's smoking status, as well as adopting Mr Gourley's matter as a case study to "highlight the importance of a comprehensive triage and of staff responsibilities".
