WARNING: this story discusses themes that may be distressing to some readers, including suicide and self-harm.
Placing an Aboriginal man in crisis into a seclusion room akin to a jail cell at Mildura Base Hospital breached his human rights, says a coroner investigating his subsequent death.
Mathew Luttrell, 43, took his own life just hours after being discharged from the hospital in November 2018.
The Yorta-Yorta father of five had been admitted because of a prior attempt on his life and ongoing suicidal ideation, Coroner Audrey Jamieson found.
He was placed in a seclusion room, which multiple witnesses reported was "culturally unsafe for any Aboriginal person" and found by the coroner to be a breach of his human rights.
After attempting to self-harm, a doctor reported he had become more settled and Mr Luttrell was offered the choice to remain in seclusion or be released into the community with support.
Both were ill-considered, the coroner reported.
He wanted to remain on the ward as a voluntary patient but was not allowed, and he was instead released on November 13 with a note that he "should not be admitted due to the unacceptable risks posed to patients and staff" and that if he returned police may need to be called.
That note breached his human right to the highest attainable standard of healthcare, the coroner found.
While Mr Luttrell's death may not have been preventable long-term, it would have been preventable in the short term if he had been meaningfully engaged with during his in-patient stay.
"While it cannot be said the hospital caused Mathew's passing in perpetuity, given the tragic outcome that followed his discharge, any potential for improvement should be identified, considered and pursued," Ms Jamieson said.
She found his time at the hospital was characterised by the inability of most clinicians to establish a respectful and trauma-informed therapeutic relationship with him.
Because he presented in a crisis state, the responsibility lay with clinicians to engage with him.
Ms Jamieson said the hospital's human rights culture required attention, close consideration and improvement.
She found the hospital failed to seek cultural support for Mr Luttrell, and failed to ensure he was provided culturally specific care, treatment and follow-up.
In her formal recommendations, the coroner has called for cultural awareness training to be rolled out as a priority for staff in its mental health unit, and that the hospital work to develop mandatory training for clinicians in diagnosing and treating borderline personality disorder.
Mr Luttrell, described by family as a kind, bubbly and intelligent larrikin, had a prior diagnosis of borderline personality disorder.
He was also diagnosed with ADHD, chronic poly-substance abuse and had a number of physical health conditions.
He had moved to Mildura in 2015.
The coroner noted Mildura had the highest average annual suicide rate in Victoria between 2010 and 2019.
"Tragically, Mathew's passing forms part of a pattern in the Mildura region of disproportionate suicidality and self-harm among First Nations communities residing there," Ms Jamieson said.
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