Teen’s suicide could have been avoided if more mental health services were available, coroner finds

The suicide of a 16-year-old boy could potentially have been prevented if more mental health services were available in Tasmania, a coroner has found.

WARNING: This story contains details that readers may find distressing.

The teenager’s body was found on Bonnet Hill in Hobart’s southern suburbs in March 2017, two days after he had been released from a private mental health clinic in Melbourne.

Coroner Kenneth Stanton found that the mental health of the boy, whose name is withheld for legal reasons, had deteriorated in late 2016 and he began treatment for depression in October.

After telling his doctor that he had regular suicidal thoughts, he was admitted as an inpatient to two Victorian facilities and spent nearly three weeks at the Albert Road Clinic (ARC) in February 2017.

He was released from the ARC on March 4, with a plan for him to return to the facility a few weeks later for further treatment.

But two days after he was discharged, and a day before he was due to return to school, the teenager took his own life.

Stanton said the boy’s death was “a source of deep sadness and intense pain to his family and friends”, noting that his mother took her own life after his death “as a result of the understandable pain she experienced”.

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The coroner found that ARC psychiatrist Christine Simons should have given the boy’s parents more information about the increased risk of suicide in the first few days after discharge from an inpatient facility, as well as informing them that she had discussed how and where he could take his own life.

“Dyed [the boy’s] If the parents were aware of those specific issues, they may have been able to take additional steps to prevent her from going to the place where she took her own life, particularly during the high-risk period shortly after discharge,” Stanton said.

Dr. Simons provided evidence to the investigation that the child was in a safe and stable condition and that she was confident that he could be safely discharged.

He also said that he interpreted the discussion of suicide methods as a sign of distress and not necessarily as declarations of genuine intent.

Inpatient options in Tasmania ‘less than ideal’

The coroner said the teenager’s mother wanted him to be treated at an inpatient facility, and the lack of adequate facilities for teenagers in Tasmania meant he was admitted to the ARC.

It found that the boy had “experienced the disadvantages of interstate treatment as an inpatient” despite his parents’ best efforts to support him.

child looking out the window
There was no adolescent mental health ward suitable for the boy in Tasmania.(ABC News: Lucas Bowden)

“It would have been preferable to [the boy] having been treated close to home.

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The coroner found that the boy would have had to be admitted to the Royal Hobart Hospital for inpatient treatment in Tasmania, which would have seen him hospitalized in a pediatric ward that did not specialize in adolescent mental health, or in an adult psychiatric ward. pavilion.

“It is uniformly accepted that neither of these options is appropriate,” Stanton said.

“All of the professional medical experts who testified in the investigation agreed that treating youth in hospital wards that are not specifically designed for adolescent psychiatric care is not ideal.”

The state is still waiting for new mental health facilities

In 2015, Coroner Olivia McTaggart made sweeping recommendations on how to improve mental health services for young peopleafter the suicides of six teenagers.

Those recommendations had not been implemented at the time of the boy’s death, but Prime Minister Peter Guwein has announced plans to create adolescent mental health wards at both the Royal Hobart Hospital and Launceston General Hospital.

Mental Health Minister Jeremy Rockliff says beds are now available at both hospitals for adolescent patients with mental health problems.

Chief psychiatrist Aaron Groves told the inquest that there were proposals to create community facilities for adolescent patients in the state, rather than hospitals, but Stanton found that many of them “would still take years to implement.”

“On the evidence before me, I cannot exclude the possibility that the availability and referral to community services in the following days [the boy’s] discharge from the Albert Road Clinic could have led to a different outcome,” he said.

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Gutwein said the government was implementing the recommendations of a 2020 review of mental health services for children and adolescents and would consider the coroner’s recommendations.

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