Disturbing footage has documented the "horrific" death of a patient in a NSW hospital after she was locked, naked and chemically restrained, in a seclusion room with no food or water at Lismore Base Hospital.
The horrific vision on Friday prompted NSW Health Minister Brad Hazzard and Mental Health Minister Tanya Davies to launch a parliamentary inquiry and an independent investigation into the use of seclusion and restraint of mental health patients across NSW.
Mother-of-two Miriam Merten died after falling at least 20 times and hitting her head as two nurses responsible for her care watched from a security monitor and ignored her pleas for help.
Ms Merten died on June 3, 2014 from "traumatic and hypoxic brain injury caused by numerous falls and the self-beating of her head on various surfaces", shortly after she was removed from her tiny seclusion room in the hospital's mental health unit, a NSW coroner found after viewing the footage.
The 46-year-old, who was well known at the hospital, had been locked in the room for more than five hours from 11.50pm to 5.10am, "sedated with psychotropic drugs", with no water or toilet and no contact with the nurses on shift.
The footage - first published by News Ltd - shows Ms Merten falling to the floor numerous times in the bare room with only a mattress on the floor.
The two nurses monitored the patient only via a video monitor, against NSW Health protocols that require frequent contact to check on a patient's wellbeing.
It was "inconceivable that the nature and number of falls were not observed" by the nurses, the coroner's report concluded.
"The deceased was provided with no proper care following the obvious falls between 6:38:44am and 6:49:41am ??? and indeed was treated with complete indifference," the coroner found.
"No effort was made to assist in having her attired except by apparently throwing a gown [in] the room," his report read.
The footage shows Ms Merten emerging from the seclusion room and "wandering the corridor naked and covered in excrement while the senior nurse is seen to mop the floor apparently oblivious", the coroner said.
"The lack of care and compassion shown to the deceased was monumentally disgraceful and appeared to emanate from an 'Oh, it's just Miriam' mentality," the coroner's report read.
"To see a mentally ill person in 2014 at a public hospital in NSW treated in such an appalling manner is really beyond comprehension."
The coroner concluded the incident was not a system failure but a "human failure".
The senior nurse on duty blamed a lack of adequate staff numbers for the death.
But the coroner concluded the senior nurse had deliberately made a decision not to comply with hospital protocols and had "no intention to cease the seclusion during her shift".
The two nurses involved - including a junior nurse told to ignore guidelines - were referred to the medical watchdog and sacked over the incident.
The Northern NSW Local Health District launched an internal investigation after Ms Merten's death, and has since increased mandatory training for mental health staff, NWLHD chief executive Wayne Jones said in a statement.
Investigation into seclusion across NSW
Mr Hazzard and Ms Davies, who said they first saw the footage on Thursday, appointed NSW chief psychiatrist Dr Murray Wright to head an independent investigation into the policy and practice of seclusion, restraints and observations across the entire NSW mental health system.
"When I saw it, it was just terrible. It was shocking to think that anybody could be treated the way she was treated. It is beyond disturbing ??? to think that somebody with any health issue could be so callously ignored," Mr Hazzard said.
"This poor woman was treated in a way that none of us could ever really have imagined."
Ms Davies said at one point she closed her eyes because the vision was too horrible.
Dr Wright said the staff involved "failed on every level".
"I think this is an extraordinary incident ... I have no evidence in front of me that this kind of abhorrent behaviour is systemic," Dr Wright said.
The state government will also request the Legislative Council to reopen its submissions for its inquiry into the management of health care delivery in NSW to allow mental health care to be addressed.
Seclusion a 'huge problem' in hospitals
Dr Wright said Australian governments have been working to improve seclusion practices -a "treatment of last resort" - for the past decade.
"Whilst we've made progress, there is still clearly plenty of room for improvement," he said, stressing the ultimate goal was to eliminate seclusion altogether.
Several psychiatrists and mental health experts have spoken out about the systemic issue of seclusion and restraint - both physical and chemical - being overused in NSW hospitals and nationally.
"Seclusion is incredibly traumatic.The patients never forget it," a NSW public hospital psychiatrist told Fairfax Media.
In 2005, health ministers endorsed the national safety priorities in mental health, including "reducing use of, and where possible eliminating, restraint and seclusion".
The health ministers agreed seclusion and restraint were serious infringements of an individual's rights, and can cause psychological trauma and physical injury to consumers and to health-care staff.
Recent national data shows that, on average, NSW patients are secluded just under 8.7 times for every 1000 days in a public health facility in 2015-2016, though the rate has dropped from 10.6 times in 2011-2012.
Patient's daughter left in the dark
Ms Merten's daughter, Corina Leigh Merten, said she only learned the full extent of her mother's horrific experience when she was recently contacted by a journalist.
The 20-year-old told the ABC that hospital nurses initially gave her a different account of the incident and did not know a coronial inquest was underway.
"I was in school, in year 12, my dad came and picked me up and we went straight to the hospital," she said.
"I'm so disappointed that it took a reporter for me to know what actually happened to my mum," she said.
Mr Jones said the LHD provided open and full disclosure to Miriam Merten's guardian and father concerning the details of her death.