On July 17, staff at the Mental Health Observation Unit discovered Joe Gumley in his room with ligature marks around his neck and bleeding from a head wound, sustained from an electric guitar he was allowed to keep in room. His roommate, Paul Hindmarsh from Gerringong, has been charged with his murder.

The report lifts the lid on a broken system, in which nursing staff failed to carry out requisite checks on those in their care but signed forms to say that they had. It found no risk assessment had been carried out on allowing a guitar to be kept in a room. 

Worse, it revealed a lack of understanding among staff about the role of the mental health unit – whether or not it was an observation or high-dependency unit. This lack of definition led to an absence of an appropriate model of care for patients. 

The report also showed that attempts to have Hindmarsh transferred to another facility better equipped to treat him had failed.

Residents of NSW have every right to demand more from the health system. At the very least they should be assured that when that system takes their loved ones into care, they are taken out of harm’s way, not placed in danger.

The review announced by new Illawarra Shoalhaven Health District chief executive Margot Mains is welcome but comes too late for Joe Gumley and his grieving family. It is beyond tragic that a patient had to die for the health authorities to finally realise there was something chronically sick about the system for which they were responsible.