When her son died inside a mental health unit, Donna Knight was determined to make change.
Jamie Knight died by suicide at age 24 while an inpatient at Gosford Mental Health Centre, a psychiatric ward on the grounds of Gosford Hospital.
Miss Knight thinks of Jamie every day.
"I miss his smile and our banter. We were very close. We'd talk about everything and anything," said Miss Knight, of The Entrance.
Shine Lawyers is representing Miss Knight in a medical negligence claim against Central Coast Local Health District over her son's death.
A statement of claim alleged "the design of the ensuite door" in Jamie's room at the mental health unit was a factor in his death on February 3, 2022.
Jamie was taken to the hospital's intensive care unit after a suicide attempt at the mental health unit, but died three days later from a lack of oxygen and blood to the brain.
Miss Knight said a duress button that could have got help for her son sooner wasn't working.
He was at the mental health unit for eight days before he died.
The statement of claim alleged the health district "failed to carry out any risk assessment of the design of the doors of the mental health unit prior to construction and/or installation".
The statement also alleged the health district "failed to install outward opening anti-ligature doors in the ensuites of the mental health unit".
After her son's death, Miss Knight met health officials.
"You can't just sit people down at a polished table and tell them you're sorry. That's not good enough," she said.
"Instead of burying my head in the sand, I said 'changes need to be made here'.
"I managed to get all the ensuite doors removed out of there. I also got them to remove cupboard doors. I dug in and got as many changes as I could."
Miss Knight said she was "happy I stood up and called it out".
"It never saved Jamie's life, but hopefully it saved someone else's life," she said.
Shine Lawyers medical law solicitor Ashleigh Vettier said the case "raises serious questions about whether Jamie's known suicide risk was appropriately managed by the facility responsible for his care".
"Our case is that Central Coast Local Health District owed Jamie a duty of care and failed to take reasonable steps to protect him, including adequate monitoring and risk management while he was an inpatient," Ms Vettier said.
Ms Vettier said the claim sought "compensation for the harm and loss suffered as a result of Jamie's death, including the psychiatric injury and grief-related loss experienced by his family".
"This is not just about what happened to Jamie. It is about whether the systems intended to protect people at high risk of suicide were followed, and whether those systems were sufficient," Ms Vettier said.
"Where a facility identifies a patient as high risk, there must be clear, documented and consistently followed protocols for observation, escalation, removal of ligature risks, clinical review and family communication."
Miss Knight said she was seeking compensation because "I've suffered a significant financial loss".
"I haven't been able to work since because of depression. I don't know when the grief train is going to pull into the station," she said.
Miss Knight said Jamie was "outgoing and had a lot of mates"
"He was quick-witted and worked in the security industry. He liked music and loved football. He followed the North Queensland Cowboys," she said.
"He valued his friends and was a much-loved son, brother, uncle and nephew."
She said his mental health troubles started in his teens "when he was getting bullied at school".
"When it started consuming him, he attempted to take his life a couple of times. I talked him into going into Gosford Mental Health Centre. He'd attempted to take his life the night before," she said.
Of the health officials that apologised to her, Miss Knight said "saying sorry doesn't really cut it for me".
"They get to go home to their kids and watch them have their first child and get married. They get to have Christmas and mother's and father's day with their kids. I've lost all that. I've lost everything," she said.
"Maybe people sitting in some of these jobs shouldn't be there. Someone should be accountable."
A Central Coast Local Health District spokesperson said it "extends its sincere condolences" to Jamie's family and friends.
"As this matter is before the court, it is not appropriate to make any further comment," the spokesperson said.
