A Tasmanian coroner has found shortcomings in the care provided to a man with schizophrenia by the North West Regional Hospital in Burnie led to his preventable death in 2016.

Key points: Nigel Douglas Roberts died in 2016 after being given too much sedating medication and not having his breathing adequately monitored, a coroner found

Nigel Douglas Roberts died in 2016 after being given too much sedating medication and not having his breathing adequately monitored, a coroner found The coroner recommended the North West Regional Hospital improve patient handover and monitoring procedures

The coroner recommended the North West Regional Hospital improve patient handover and monitoring procedures He also recommended the Tasmanian Government establish supported accommodation on state's north-west coast for people with psychiatric illnesses

Coroner Rod Chandler found Nigel Douglas Roberts died in the hospital's Spencer Clinic on January 31, 2016 because medical staff gave him too much sedating medication and didn't adequately monitor its effect on his breathing.

Mr Roberts suffered from schizophrenia and had been brought to the hospital from the Karingal Nursing Home in Devonport the previous day because he had been behaving aggressively and erratically and had punched a staff member in the face.

In his findings, Mr Chandler said in response to the 55-year-old's continuing aggressive behaviour, staff at the North West Regional Hospital restrained Mr Roberts and gave him the sedative drugs olanzapine and clonazepam.

He found the interaction of these prescribed medications with Mr Roberts' physical illnesses, including advanced emphysema and bronchopneumonia, caused Mr Roberts' death.

Mr Chandler said medical staff should have monitored Mr Roberts' respiration more carefully and frequently.

"The evidence shows that the medical staff involved in Mr Roberts' care were alert to the risk of this outcome and it was thus incumbent upon them to take all possible steps to minimise this risk," Mr Chandler said.

"This included the need for a strict regime to be in place to monitor Mr Roberts, most particularly with respect to his respiration.

"Unfortunately this did not occur with his otherwise preventable death being the consequence."

The Tasmanian Health Service (THS) undertook its own review into Mr Roberts' death and concluded that there was a lack of communication between the services caring for Mr Roberts, and a failure to develop a comprehensive management plan for Mr Roberts' psychiatric and physical illnesses.

The review recommended developing better communication between clinicians, better handover procedures when a patient's condition is deteriorating and better patient monitoring procedures.

Mr Chandler endorsed the THS review's recommendations and urged the THS to continue to implement them.

Not enough supported accommodation for young people

Mr Chandler found the Karingal Nursing Home did its best to provide Mr Roberts with a safe and caring home, but as an aged cared facility was not suited to care for younger people suffering from serious mental illnesses.

"Mr Roberts' psychiatric illness, his behavioural issues, and his physical ailments presented a serious challenge for Karingal staff, and there were many instances where they had difficulty coping," Mr Chandler said.

These included incidents in which Mr Roberts behaved in an aggressive and sexually intrusive manner, slept on the floor in public areas of the home, harassed a staff member who was from Tonga and claimed that staff were not providing him with oxygen when he needed it.

"This circumstance leads me to recommend that Tasmanian Health Service, in concert with other relevant governmental authorities, co-ordinate a strategy to establish a suitable facility on the north-west coast which can provide supported accommodation for persons suffering from mental illness and who are unable to care for themselves," Mr Chandler said.

The Mental Health Council of Tasmania agreed there was generally not enough suitable long or short-term supported accommodation available for people suffering from psychiatric illnesses.

However, the council's CEO Connie Digolis said the Government should first evaluate what was needed and what was already available.

"To actually start getting an understanding not just of the region, but the needs, where people are, where their needs aren't being met, and how they can actually be addressed would of course be something that we'd welcome," Ms Digolis said.

"We want people to be living the most productive, comfortable life that they can.

"An option of a residential aged care home for anybody who is young, we would say couldn't be helpful for their longer-term quality of life."

The Tasmanian Health Service has been contacted for comment.

