DOCTOR REVEALS: 'It does change what I would have done'
A hospital's approach to Carley Metcalfe's care may have been different if more information was available, the inquest into her death has heard.
Ms Metcalfe, 41, was taken by ambulance to Lismore Base Hospital in a disoriented state about midday on November 1, 2017.
After being medically cleared, she left early the next morning and then was missing for weeks before her body was found on the shore of the Brunswick River near Mullumbimby.
Dr John Wardell, who was the on-call consultant psychiatrist at the time Ms Metcalfe was in hospital, appeared as a witness in the inquest before Byron Bay Coroner's Court on Wednesday.
He is now the director of medical services for mental health, alcohol and other drugs for the Northern NSW Local Health District.
Dr Wardell told the inquest he was guided by on-duty psychiatric registrar, Dr Robert Byrne, in considering whether Ms Metcalfe was suitable for admission to the mental health ward.
Both doctors have told the inquest they agreed she should be held overnight in the emergency department while they awaited a urine drug test - to confirm or rule out drug intoxication - and that she should have been reassessed for potential mental health admission the following morning.
Ms Metcalfe had been previously diagnosed with schizophrenia, and had a history of psychosis.
The inquest has heard evidence she had stopped taking her antipsychotic medication and methadone.
Dr Wardell agreed with counsel assisting the Coroner, Kirsten Edwards, that Ms Metcalfe's death was "a tragedy".
When asked what he would have liked to have occurred, in hindsight, Dr Wardell said he would have preferred for her to have not been discharged in the manner in which she was.
"I would have liked for her to have remained in the Emergency Department until the morning when she could have undergone another, probably more comprehensive and complete, mental health assessment," Dr Wardell said.
He told the inquest Dr Alexander Pullen, who was in charge of the emergency department at the time, presented them with a "binary choice"; Ms Metcalfe could be admitted to the psychiatry ward or discharged from the hospital altogether.
He said there was "no option" to admit her to the mental health unit at that stage, but it was common practice for a patient to be held in emergency and reassessed in the morning, with the benefit of more information.
"At the time her symptoms were presented to me, it appeared clear to me that she would not be suitable to admission due to her level of confusion," he said.
He said there was an "accepted guideline" that the mental health unit does not accept substance-affected patients "until that intoxication has cleared and they become more settled".
The inquest has heard evidence that when Dr Pullen assessed Ms Metcalfe later on in the night, he did not find her to be acutely intoxicated.
"Would that have made a difference to you (that) there had been some dispute with an emergency staff specialist about her level of intoxication?" Ms Edwards asked.
Dr Wardell replied: "yes".
Ms Edwards asked if there was a "missed opportunity" for more discussion about Ms Metcalfe's actual level of intoxication, and Dr Wardell agreed.
"Putting that into the equation it does change what I would have done," Dr Wardell said.
"It would have been better if you and Dr Pullen and Dr Byrne had, at some stage, discussed Carley as a conundrum that needed to be solved … and not a person who was subject to a demarcation dispute?" Ms Edwards asked.
Dr Wardell replied: "that would have been preferable".
The inquest continues.