Two nurses at Lismore Base Hospital on the New South Wales north coast have been found guilty of professional misconduct by the state’s Health Care Complaints Commission, after a patient died of a brain injury due to 24 falls while in their care.

The patient was filmed wandering naked and covered in faeces in Lismore’s Adult Mental Health Unit in mid-2014. Closed-circuit television (CCTV) footage showed that in the seven hours before she was transferred to intensive care she fell 24 times. For most of that time she was alone in a locked room, but the nurses’ records made no mention of any falls.

During her five hours in a seclusion room, no-one entered to check her temperature, pulse, respiration or blood pressure, and she was not offered any food or water or access to a toilet.

The woman died from a brain injury the following day.

Since the patient’s death, an internal investigation has been conducted into the area health service and a number of changes to its mental health unit operations have been made.

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