Tasmania’s Mental Health Service (MHS) has come under heavy scrutiny following a coroner’s findings that it failed to take meaningful action to prevent the tragic suicide of a 27-year-old woman. The coroner’s report highlighted the lack of support and intervention from the public mental health system.
The young woman’s case was referred to the MHS by a general practitioner on July 4, 2020, after she expressed suicidal thoughts, accompanied by a history of suicide attempts. However, during the ensuing three weeks, no efforts were made to meet with her in person.
Tragically, on July 28, 2020, she took her own life.
In a report released on Monday, Coroner Simon Cooper detailed the deficiencies in care that led to the woman effectively receiving no assistance from the public mental health system. Her case had been assigned to the Hobart Crisis Assessment and Treatment Team (CATT). Still, initial attempts to contact her by phone were unsuccessful, and when she reached out to request a meeting with her treating psychologist, her plea went unanswered.
During this time, her case was discussed at five multidisciplinary meetings, but no substantive decisions were made except to transfer her to another team after noting her change of address. Shockingly, her name was subsequently removed from the team’s whiteboard.
Although the woman managed to speak with the team twice over the phone to seek updates on her case, the responses she received were far from adequate. On the first occasion, she was directed to contact Centrelink or housing support. In her second call, she expressed fears of a severe relapse, but her case was inexplicably closed three days later, with no further referrals.
Eight days after this closure, she tragically took her own life.
Coroner Cooper was scathing in his assessment of the care provided, citing severe deficiencies. “There was no proper attempt to establish a therapeutic relationship with her, and in real terms, [the woman] received no treatment whatsoever, at a time she plainly needed it,” he stated.
He further criticized the multiple team meetings, stating that they did nothing meaningful to support her.
“I have reached the view that [the woman] was very poorly served by the state Mental Health Service,” Coroner Cooper concluded.
The Crisis Assessment and Treatment Team (CATT), comprised of psychiatric nurses, social workers, psychiatrists, and psychologists, is intended to provide immediate help during mental health crises and operates at the state’s major hospitals.
Following the tragic incident, the Tasmania Health Service (THS) conducted a root cause analysis report into the woman’s death, which yielded undisclosed recommendations. Coroner Cooper expressed his support for these recommendations.
