No one to watch over him

On the night Bayden Smith took his own life, health workers sent him home, convinced he was not at risk. An inquest into the matter is attempting to discover how such a tragic miscalculation was made.
BAYDEN Smith was a blokey kind of bloke. For most of his working life he was a butcher. He liked to sink a few Cougars watching car races on TV with his mates. He loved to ride motorbikes and to hunt – he’d shot buffalo in the Northern Territory – and owned six rifles.
They got him into trouble, those rifles. On a trip to Deniliquin, he shot a few protected birds. He was caught with them in the back seat of his car and was told he could face thousands of dollars in fines.
It preyed on his mind. He was already struggling financially; somehow, his once-steady work history had degenerated into a string of casual jobs – four in a month, at one point. He started drinking heavily. “To keep up with his job status was a pretty big challenge,” his son, Bayden junior, told the Coroner’s Court this week. “I knew he was having days off here and days off there.”
His friends saw Bayden senior as happy-go-lucky but his son, who continued to live with his dad in a rented house in Greenvale after his parents’ divorce three years earlier, knew better. His father was a bottler who hid his troubles behind a bright social veneer: “He put on a very good show that he was happy. But when nobody else was around, when he was at home, he was sad and depressed … My Dad, if he was feeling something, he didn’t want to show people he was feeling it.”
On the last night of his life, the people from whom he hid his true feelings came to include two workers from an emergency mental health team called to a police station to assess whether he was suicidal. They found him cheerful and relaxed and were convinced that he was no danger to himself or anyone else. They released him. He was taken home by a friend who left after having a soft drink with him.
Smith’s then 18-year-old son found him dead the next day. He had shot himself with an unregistered handgun, the existence of which he had hidden from police and from his son. He was 47.
The decision to send him home is now being scrutinised by State Coroner Jennifer Coate. Her inquiry this week turned a spotlight on the workings of the mental health Crisis Assessment Teams that attend anyone who appears to be having a serious breakdown or psychotic episode to decide whether they need treatment and whether they are at risk of harm.
The central questions about that night are whether the CAT workers placed too much weight on what Smith told them and too little weight on the dire circumstances in which police found him; whether they should have sought out his family or close friends, who would have told them the truth about his state of mind; and whether they should have confirmed for themselves that someone would stay with him that night rather than taken his word for it.
Coate has also been trying to establish how the CAT system works and how it is overseen: are there system-wide manuals and guidelines telling workers how to assess risk? Is there central oversight and investigation of tragedies such as Smith’s? Does the psychiatric system keep detailed statistics on what the teams do and assess how effective they are?
The answers so far have been no, no and no. On the night of October 17, 2006, Bayden Smith came home to an empty house. He was upset. He and his son had had a row the week before and his son, fearing his father might become violent, had called police. The officers suggested Bayden junior move out for a few days to allow things to settle.
Although they spoke on the phone at least every day that week – seven times on one day – Bayden senior was feeling abandoned. He later told the CAT team that he felt his son had rejected him the way his wife had. He was also having problems with his 21-year-old girlfriend. He sat down in his lounge room, took off all his gold jewellery and wrote a suicide note.
But he also phoned several friends to tell them what he was doing, and one of them called police. When they arrived, one officer told the court, it was clear that Smith had been weeping. Police took his registered guns and made him walk them through the house to search for more before driving him to Broadmeadows police station and calling the CAT team.
The two workers rostered on with the North-West Mental Health Service were Kok Lim, a psychiatric nurse, and Quan Nguyen, a social worker. In an ideal world all crisis assessments would be done by a psychiatrist, North-West clinical services director Dr David Muirhead told the inquest, but “there simply aren’t enough psychiatrists to be able to do all of these assessments, even if you had the money to employ them”.
By the time the workers arrived at the station Smith had pulled himself together. He told them his mood was “good, happy” and their notes record his “affect”, or apparent emotional state, as “bright”. He told them he had just had an angry moment when he was writing the suicide note, that he did not intend to harm himself and that he had to be up at 4.30 the next morning for work. He agreed to talk to them on the phone the following day.
He was so relaxed and so apparently co-operative, Nguyen told the inquest, that there seemed no need to verify what he was telling them.
The workers were also reassured by the fact that the police had taken his guns. “The initial threat of death by shooting, at the time we sent this man home, was no longer there …” Lim told the court. “The central risk and central means of suicide had been removed at a stroke.” The final assessment: Smith was “low-risk”.
Smith rang his friend Charlie Mazza and told him he was allowed to go home as long as a friend was with him. Smith told the CAT team Mazza would stay with him that night. Mazza told the inquest that he had never agreed to stay the night – he had to be up for work at 4am himself – and that he was worried about Smith being released into his care.
“I never spoke to anyone from the CAT team,” he said. “To be honest, I was really disturbed that they released him in my care. I am no professional. Common sense tells you that if a person has written a note and is about to do himself in there should be a bit more support there.”
Coroner Coate asked Nguyen whether the CAT team had turned their minds to the possibility of a “classic trap” described by an expert witness, past professor Dr Richard Ball, director of psychiatry at StVincent’s Hospital.
Reviewing the case, Ball wrote: “There is a classic trap as outlined by Stengel and others very long ago, and that is a paradoxical state in which someone who has been depressed, and has possibly thought of suicide, becomes calm, relaxed, overtly not distressed and overtly co-operative and not ill because the die is cast. The decision has been made to die and the means is already planned. Maybe this was the situation with this man.
“It has occurred on numerous occasions, is very dangerous and can easily throw people off the track.”
Nguyen told the court that they had not seen it that way. Muirhead defended the workers and their decision. He said they made the right call on the information that was available to them at the time. “Unfortunately the right decision can have the wrong outcome.”
He said it was regrettable that they had not checked personally that Mazza would be staying with Smith but denied that it was common practice to discharge seriously disturbed people back into the care of friends or family.
“You wouldn’t usually expect that family members or friends should conduct some kind of suicide watch,” he said. Mazza’s presence would simply have been intended to help protect Smith against feeling alone and desperate, he said.
“Would it have been helpful for Mr Mazza to have had some understanding of that?” asked Senior Constable Greg McFarlane, for the coroner.
“Yes, it would have been,” acknowledged Muirhead.
Muirhead told the court that between August 2007 and July 2008, his service had provided 1044 new CAT assessments. Of the 204 assessments initiated by police, 87resulted in people not being admitted, a rate of 42.6%. Muirhead said he did not believe any of those 87 non-admissions had ended in death.
He said there was no manual with guidelines for CAT workers because they dealt with such a wide range of experiences it would be impossible to compile a manual and because practical education was more important than manuals “that would gather dust on a shelf”.
Victoria’s Chief Psychiatrist, Dr Kuruvilla George, was asked whether he was concerned that there seemed to be little in the way of written policies relating to CAT teams.
He said: “I agree that there are probably no policies or procedures (written down) on a CAT team, because there are so many teams. But … I would be very surprised if health services didn’t have policies for assessments.”
George said that since the decentralisation of mental health that had followed the closing of Victoria’s last asylum in 1997, individual services were largely responsible for developing their own guidelines and investigating most of their own adverse incidents. The exceptions were incidents relating to in-patient deaths, electroconvulsive therapy and the practices of seclusion and restraint.
He said there were better statistics on these matters than there were on CAT teams, which had not been openly and independently assessed since they were set up in the 1990s. “There’s a capacity for drilling in but that’s not done by the department.”
The inquest is due to resume on December 2.
Karen Kissane is law and justice editor.
For help or information visit, call Suicide Helpline Victoria on 1300 651 251, or Lifeline on 131 114.

First published in The Age.