Deputy State Coroner Anthony Schapel warns that detaining mental health patients together in psychiatric wards is “a highly undesirable practice” and says it was “a certain inevitability” someone would be killed.

He has recommended to the Health Minister and SA Health that dual occupancy of rooms in psychiatric wards in public hospitals “no longer be permitted”, saying “it was not so much a question of whether such an incident would occur and when, but to whom”.

His recommendation follows an inquest into the death of a patient in the psychiatric ward of Noarlunga Hospital – the Morier Ward – in August 2014.

Stephen John Barton, 43, was strangled to death in the middle of the night as he slept by his 23-year-old roommate Lindon Sekrst, who was suffering from an ice-induced psychosis.

Sekrst was found guilty of murder but that conviction was quashed and he ultimately pleaded guilty to manslaughter.

In October 2017 he was sentenced to more than seven years in jail.

In his findings delivered today, Schapel said Barton’s death was discovered about 1am on August 12, 2014, only a few hours after Sekrst had been admitted to the ward, after spending three days in the Noarlunga Hospital emergency department.

“The last routine hourly check had occurred at about midnight and nothing untoward had been observed,” he said.

“The practice of requiring detained patients in an open ward to be dually accommodated is a highly undesirable practice.

“This is especially so when in the first instance little is known about the background of a newly admitted patient. It is also especially so when it is believed that the newly admitted patient is experiencing paranoid ideation and where routine checks on that patient are spaced as far apart as an hour.

“Since the events with which this inquest is concerned the mental health authorities in this State have been on notice as to these circumstances.”

Schapel said he was told in evidence that Morier was the only psychiatric facility in the public mental health system in which some rooms were dually occupied.

“I was also told that Morier was generally full, which meant that at any given time there would be ten patients occupying the five double rooms,” he said.

Schapel acknowledged “there was no overt indication that Mr Sekrst would harm anybody”.

“However, given the practice of dually accommodating patients in the open ward of Morier, there seems to have been a certain inevitability in an incident of this kind occurring at some point in time,” he said.

“It was not so much a question of whether such an incident would occur and when, but to whom.

“To my mind this state of affairs continues as long as dual accommodation arrangements exist at Morier.”

Both men had been detained in the same room of Morier under Inpatient Treatment Orders under the Mental Health Act.

Schapel called four witnesses during the inquest who had a connection with the Noarlunga Hospital and Morier – two psychiatrists and two nursing staff.

“All four clinicians were unanimous in their view that dual accommodation in the open facility of Morier was an undesirable circumstance,” he said.

“Various reasons for that observation were expressed. They were all compelling.”

Schapel said one of the psychiatrists testified that “people in Morier were doubled-up for resource considerations alone; that there were not enough single rooms to cater for the number of people on the ward”.

InDaily contacted SA Health and Health Minister Stephen Wade for comment.

An SA Health spokesperson said: “We are reviewing the Coroner’s findings handed down today and will consider the recommendation in detail.”