9 Year period – received 26th June 2003

Cases involve complaints from family members/friends about the suicide or attempted suicide of persons involving the alleged failure of professionals to communicate with, or involve family or carers. Common themes in the complaints are also:

  • the early release of patients who then take their own life;
  • an allegedly inadequate assessment made of patients.

A woman with a long history of psychiatric illness and attempted suicide was not regulated at a general hospital despite repeated requests by her carers. The carers were from a supported accommodation service, and had extensive information about her patterns of behaviour. She had been admitted as voluntary patient after two suicide attempts, but later discharged herself and swallowed caustic soda, and was urgently admitted to intensive care at another hospital. She was dangerously ill and her speech and digestion were impaired. She chose the agency to act for her in complaining about negligence, and the agency and hospital agreed on conciliation in an effort to resolve the issues.

A father who made a suicide attempt by overdosing on pills was discharged from hospital while he was still drowsy, without any funds, and without his family’s knowledge. The hospital hadn’t offered him or his family any guidance on further treatment. The hospital apologised for the communication breakdown and offered the family an assurance this would not happen again.

A young woman was admitted to the psychiatric ward of a public hospital, and was discharged after five days when she said she wanted to leave. She then disappeared, except for phone calls from another town, but was then returned by ambulance to the hospital. A family member who spent much time by her bedside was told she had had an ‘ccident’, but she was then discharged again. The same night she committed suicide, and only then did the complainant discover from police that the accident was an earlier suicide attempt. He was sure that, if he had been told, he could have prevented her death. However, the hospital showed that the patient herself had directed that the complainant not be notified, as another relative was closely in touch with her.

A man in his 30’s committed suicide shortly after discharge from the psychiatric unit of a metropolitan hospital. Although his family had been aware of his suicidal tendencies beforehand, they said they were not informed by the unit of the true nature of his illness at the time of discharge, and had therefore not been in a position to take appropriate steps to protect him. Full explanations were offered to the family after interviews with the staff of the unit and examination of the patient file. These explanations had been sought directly from the hospital over a year before, but had not been forthcoming.

A suicidal woman was released twice from a public psychiatric unit despite her family’s concern for her safety. They said the hospital never acknowledged their concern and told them they were regarded as ‘ostile’. After the woman took her own life, it was established the family hadn’t been hostile. It was because the woman had become aggressive with the family (as her condition worsened), that they had been advised not to contact her. The woman had lain dead for a week and was found badly decomposed, compounding the family’s grief. The family wanted answers about what had happened, and access to her medical files, which had been denied them. The unit’s consultant psychiatrist wrote a long and detailed explanation, and they were given access to the file. They were reassured they had not been responsible for her death.

A man made several attempts at suicide. He was hospitalised in a private hospital. The hospital allowed the man to leave on several occasions even though he had previously left suicide notes. The man’s family were concerned he was not regulated under the Mental Health Act and placed under supervision The man left the hospital to go jogging and successfully committed suicide. During investigation it became obvious the man was contracting with the hospital not to self-harm, but was giving different advice to his wife. He was apparently intent on suicide, but on his behaviour at the hospital, no different course of action was indicated. Attempts were being made to engage him a therapeutic relationship. There was some breakdown in communication between the hospital and his wife.

A man said he had attended his doctor because he was distressed and had suicidal thoughts. The doctor arranged a private hospital admission. The man said he had a preference for admittance to a private hospital, as he had private health cover. While a patient of the private hospital the man attempted suicide. After the suicide attempt, the man alleged the hospital appeared to be mostly concerned with the hospital’s legal liability rather than with patient care. The man also said his partner was not told of the suicide attempt and the day following the suicide attempt it was suggested he seek treatment at anther facility of his choice. The man believed he had been treated in an unprofessional and uncaring manner by the hospital. The hospital responded, giving detail about the man’s treatment in hospital. The man accepted this response and the complaint was subsequently closed.

A woman said that her husband was admitted to a public hospital in January and August after attempting to commit suicide. She spoke at length with a nurse on staff during the August admission, advising that her husband had threatened to commit suicide once he was released from the hospital. She asked the nurse to tell the doctors to call her prior to her husband’s release. Her husband was subsequently released and committed suicide following his release, without the wife being advised. The woman said she was seeking compensation for her loss and suffering. The hospital replied that the man had a history of attempted suicide, but by the end of his most recent admission and treatment did not demonstrate any suicidal ideation. The hospital claimed that on admission the man’s history and life stressors were thoroughly assessed by a consultant psychiatrist, and he was diagnosed with reactive depression with recognisable stressors. The hospital said that the man claimed that he was glad his recent suicide attempt had failed, and no longer thought of self-harm. Since admission there had been no further evidence of sustained depressed mood or underlying psychiatric disorder. Individual counselling was identified as the appropriate treatment to develop strategies for dealing with the stressors, and a short admission was planned, as the man was keen to be discharged. The hospital said that the medical records reveal that the man’s wife had telephoned and expressed concern at his condition. The psychiatric registrar then interviewed him. At this interview the man denied any plans for self-harm. After the man’s discharge, the hospital received a phone call from the man’s friend stating that the man had said he fooled the hospital staff and intended to commit suicide. The complaint was referred to conciliation and fully explored.

A man was admitted to a public hospital psychiatric unit for his own protection after threatening suicide. The man’s mother complained that he had absconded from the hospital and was found dead later that day. The mother complained that her son committed suicide n the day he was being discharged and that the hospital should have been aware his suicide threats were genuine. The mother stated she had requested the hospital not release her son so soon. Also, according to the mother, it took 5 hours for the family to be notified of her son’s death even though there was identification on him. The mother complained that she was contacted by another public hospital requesting donation of her son’s body parts within minutes of her being advised of his death. The mother complained this hospital knew of her son’s death before the family.

A young woman committed suicide after being discharged from a public hospital’s mental health clinic. She had spent the last 3 years in and out of psychiatric hospitals and clinics and had attempted suicide previously on 5 occasions. The family of the young woman tried repeatedly to have her admitted for her safety and care. After she was admitted the young woman begged not to be discharged, but she was. At the time she committed suicide she was a regulated patient. The hospital provided the outpatient progress notes and details of the assessment undertaken. Systemic question were investigated.

A woman complained that her male cousin in psychiatric ward of a public hospital was able to leave unobserved. The woman said that the man’s son had gone to visit the man but was told that his father could have been out taking a walk. The son waited for more that half an hour and did not see his father. The man had in fact absconded and committed suicide. The woman said that she was told that he was placed under 15-minute observations. The family believed they were not consulted during treatment. The woman wanted to know how a patient who was supposed to be on regular observations could leave the hospital unnoticed and why they were not included in treatment decisions. The family had a history of suicides.

A woman said her 19-year-old son was being treated by a public mental health service for depression and psychosis. She said her son was a confessed substance abuser. She claimed the medication prescribed by psychiatrists worsened her son’s mental state. She said the hospital staff would not listen to her and did not accept her view of his need for follow up care. She believes listening to her could have avoided his taking his life.

The relatives of an indigenous boy complained that staff at a public mental health inpatient service neglectedthe care for the boy. The boy had a history of absconding from the unit and self-harming but when the boy was transferred from a closed ward to an open ward, the family were not notified and the boy absconded and committed suicide. The relative outlined the lack of cultural sensitivity by the staff, which they believed ultimately contributed to the boy’s death. The Minister requested the Commission investigate the matter and the communication issues were reviewed.

A woman complained a psychiatrist failed to advise her of her adult son’s condition. The woman explained she was the carer for her son who had epilepsy. She said her son saw the psychiatrist for deteriorating mental health. The woman said she tried to assist the psychiatrist by advising of her son’s behaviour at home. However, the psychiatrist would not tell her about her son’s condition so she could provide adequate support. The woman said she witnessed her son commit suicide and felt the doctor had failed to advise her of this risk. She felt that the doctor had contributed to this outcome by not involving family support. The woman said she would like to see confidentiality laws reviewed when risk factors were involved. The complaint was out of time and no action was possible.

The parents of a man who committed suicide stated that their son had been in the care of a psychiatric unit of a public hospital at the time. They said that during his admission he had been labelled ‘acutely suicidal’ and closely guarded for nine days. The parents stated that at the end of the nine days he was placed into an open ward and one week later he walked out and hung himself at a nearby football stand. They said that one of their main difficulties had been trying to communicate with staff who should have recognised and tapped into their intimate knowledge of their son. The parents did not know how the decision to move him onto an open ward ‘ecause he had improved’ had been reached. The parents concerns at the time were addressed by staff making reference to the fact that their son was regularly reviewed and he gave the impression that he was improving with no risk of self-harm. The parents viewed the records and believed their concerns were not recorded and should have been to be discussed with the doctor. The Commission recommended that the hospital bring this issue to the attention of all medical and nursing staff, so as to ensure that appropriate observations from family and close friends are recorded in the medical records in future. The complaint was closed.

A man said that his son was admitted as a restricted patient to an acute psychiatric unit at a public hospital by police following a violent episode at home. The man said that the hospital psychiatrist was supposed to call the father prior to his son being released, but that this was not done. The man complained that as a result, his son spent the next four days driving around in a paranoid state before contacting family who picked him up. In addition, the man said that the next day his son was again taken to the same hospital by police for suicidal and violent behaviour, but was refused admittance. He said his son left home a few days later and ended up in another State where he was admitted to a psychiatric hospital, detained and diagnosed with severe paranoia. The Commission arranged for the parents to meet with personnel from the mental health service to discuss their concerns, which satisfied the complainant and the complaint was closed.

A woman said a public hospital failed to admit her adult son who had been diagnosed with severe clinical depression. She said the hospital was also made aware that her son was suicidal but the hospital chose to refer her son to a community mental health unit for treatment even though he was severely depressed and suicidal. The woman said her son committed suicide three weeks later at home. Both the provider and complainant agreed to participate in conciliation.

A woman said her 18-year-old son committed suicide 4 months after being assessed at a public hospital. She said the hospital did not spend enough time assessing her son before he was released as he was only kept there for a short time and not admitted. She said that he was found to be suffering from anger management problems made worse by drugs and alcohol which was not an appropriate diagnosis. She said the hospital disregarded what she and her husband told them about his long history of suicide threats, aggression and depression. She also believed that she and her husband should have been given information about suicide prevention or referral agencies. The hospital said thorough assessments were conducted by a nurse and doctor in the Accident and Emergency Department and by a psychiatric registrar. It was stated that the man told two different staff members he was not suicidal. The man was found to be suffering from anger management problems and was given information about relevant courses and referral agencies. It was noted that it had been four months between the hospital’s assessment and the man’s suicide and that the hospital had not seen him again in that time. The family’s distress at the loss of their son’s loss was acknowledged.

An independent opinion was received from a psychiatrist who believed the hospital’s assessment of the man had been reasonable based on his presentation that evening. The lengthy time between the assessment and the suicide was noted. It was acknowledged that it was often difficult to accurately predict whether a patient was serious about suicide threats or to predict when an attempt may be made. It was also noted that it was difficult to weigh the information given by the patient against what may be conflicting information given about a patient’s state of mind given by the parents/carers. Confidentiality was an important factor to be considered. The opinion and response were discussed with the woman who was very distressed as she believed the information given by families did not carry sufficient weight during the assessment of patients.