Content warning: This article contains reference to suicide. Please refer to the services at the bottom of this article for support.


Four nurses who had a duty of care over an Indigenous man who suicided in 2017 have been found guilty of professional misconduct by the New South Wales Civil and Administrative Tribunal (NCAT).

The man, referred to as Patient A, was placed on level three observation in the acute mental health unit of a Sydney hospital, which requires night nursing staff to check on the patient every 30 minutes.

On May 26 2017, it was recorded he was showing signs of “severe agitation”. That night he took his own life and was found the following day at 7.30am.

The coroner determined Patient A had passed between 11.00pm and 5.30am, meaning he was left unobserved for up to eight hours.

The NCAT found that Nurse Jill Louise Watkins, who had a duty of care over Patient A on the evening of his death, had “demonstrated a blatant disregard for patient safety” by not checking on him.

Watkins had recorded Patient A as “sleeping” at 12.30am, 5.30am and 6.30am despite not checking on the patient, had failed to record significant information about his behaviour in clinical notes, and twice made entries without adequately assessing if the patient was alive.

“This conduct posed a direct risk to the safety of a vulnerable involuntary mental health patient. It was a risk that was ultimately realised,” the NCAT said.

It’s understood Patient A voluntarily admitted himself to hospital in 2017 after speaking with his GP about suicidal thoughts. He stayed at the hospital for several days before being detained as an involuntary patient in the acute mental health unit.

It’s alleged that upon admission he said he “had nothing left” and “would not be here in a week”.

Patient A was 49-years-old and was reportedly living in his car due to recently separating from his partner. He was reported to have a worsening depression due to not being able to contact his adult children.

It is also alleged he had made attempts to take his life earlier in the year.

The tribunal said while Watkins was the most junior member of nursing staff working that evening, she “worked in an acute mental health unit where all of her patients were vulnerable and dependent upon proper nursing care for their welfare”.

“Patient A went to the hospital for help. He was subsequently admitted as an involuntary patient. He should have been safe.”

Nurse Emma Kate Brown, Nurse Mehul Mukundray Dudhela and Nurse Florence Egbufor were also found guilty by the Tribunal.

The NCAT found Brown had described Patient A as “settled” despite not physically observing him, Dudhela didn’t enter the patient’s room after 11.00pm and Egbufor recorded the man as “sleeping” despite not physically observing him.

The Health Care Complaints Commission also brought a complaint against a fifth nurse but it was found to have no foundation and was dismissed.

All four nurses were found guilty of professional misconduct under the Health Practitioner Regulation National Law.

Two of the nurses had stopped practicing nursing, and others had their ongoing registrations revoked by the Tribunal.

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By Rachael Knowles