Inquest Finds Teenager's Hanging Death In Respite Care Was Preventable

Thirteen-year-old Melissa Standon had only been in respite care for three weeks when she was found hanging from her bed after accidentally choking herself to death in 2015.

Now, more than three years after her death, a NSW state coroner has found her death was preventable.

State Coroner Les Mabbut found that Melissa died after falling from her bed at Allowah Presbyterian Children’s Hospital due to "failures to implement proper systems for risk assessment, bed selection and the training of staff for a child patient with profound disabilities."

Melissa, who suffered from physical and cognitive disabilities including cortical blindness, epilepsy, short stature, severe mental retardation, developmental delay and feeding difficulties -- needed high-level full time care.

A supplied undated image obtained Tuesday, September 25, 2018 of 13-year-old Melissa "Maisy Mouse" Standen in Sydney. Image: AAP

Up until her admission into the hospital she was cared for by her parents and other members of her family 24 hours a day, seven days a week, the inquest heard.

At 13-years-old Melissa weighed less than 15 kilograms, the average weight for a three-year-old child, and was non-verbal outside of making sounds that informed people of how she was feeling.

She was unable to sit up by herself and could only move her arms and legs in stiff motions. Her admission form completed by the registered nurse at the hospital scored her fall risk assessment at one, which declared her "completely immobile."

The inquest heard she would often "cry and move around by arching her back when her gastric reflux caused pain."

On the evening of January 13, 2015, Melissa had been crying a lot, the nurse on the evening shift, Ms Falvey, told the inquest.

Image: AAP

She was last seen alive at 11:15pm.

At 11:55pm when nurses went to check on her during rounds, they found Melissa hanging outside her bed from the top right corner.

The back of the 13-year-old's t-shirt had been hooked on the corner of the bed and her knees were seen touching the ground with her head leaning forward, in  what appeared to nurses as a praying position.

Her head was suspended approximately 2-3 inches from the ground, while her shirt put pressure on her throat area.

The girl was immediately administered CPR and taken to Westmead Children's hospital but she was unable to be resuscitated.

An inquest determined her death was by hanging and on Tuesday the coroner found several factors related to the Hospital's assessments and procedures contributed to her fall and subsequent death.

Melissa's parents leaving the Coroners Court on Tuesday. Image: AAP

These included the Hospital's failure to implement an appropriate risk assessment to manage Melissa's change from a cot to a bed, as well as using a bed that was "totally unsuited" to her needs .

The coroner found there was no evidence her bed was in the required V shape, despite the hospital earlier being told that this was the shape she was accustomed to at home.

The bed was found to also be improperly adapted  to "reduce risk given Melissa’s special needs and the inappropriate use of bumpers as a fall prevention device."

"Whatever position the bed was set in, it was insufficient to prevent Melissa moving up to the bed head and falling out," Mabutt found.

"It was conceded by the Hospital, even if the bed had been set up in a V shape, the padding on the bed was not a suitable response to the risks associated with the bed allocated to Melissa."

In its findings the coroner acknowledged Allowah Hospital as "unique" in NSW in providing a service to families and carers of children with profound disabilities.

"I am satisfied the evidence heard at this inquest reveals the Hospital has made real efforts to identify and implement procedures to address system failures, lack of staff training and culture following Melissa’s death," Mabutt said.

During the inquest CEO of Presbyterian Social Services Elizabeth McClean gave evidence of the changes implemented at the hospital in the wake of Melissa's death.

These included the implementation of a Bed Allocation Screening Tool to improve bed safety, removing the use of bumpers, utilising new beds with no gaps, increasing staff training and implementing a risk management framework.

Bruce Standen (left) and Tin Ho (right), the parents of Melissa Standen. Image: AAP

"It is the clear wish of Melissa’s family that lessons be learnt and changes occur to ensure another child is not placed at risk in similar circumstances," the coroner said on Tuesday.

"The care, love, dedication and devotion to Melissa was overwhelmingly demonstrated by her family throughout this inquest. Melissa’s family loved her, will treasure her memory and miss her terribly."

Featured Image: AAP