Three people died by apparent suicide – one in 2016, another in 2017 and a third in an undisclosed year – after being discharged from the Lyell McEwin Hospital mental health short stay unit, the documents show.
SA Health has refused to say how soon after discharge the patients died, saying the cases were before the Coroner.
But the department says the deaths were entered into the short stay unit’s records because the patients died within six months of discharge from that service.
An unidentified mental health patient died by “suspected completed suicide” in 2016, the documents say.
Another person died in 2017, in circumstances where “police are suspecting possible suicide”.
A third mental health patient died there by “suspected completed suicide”.
The entry does not disclose the year of the person’s death, unlike the 273 other adverse incidents recorded in the document.
In the space where the year should be, the listing reads: “??? SSU closed at this time”.
The deaths are listed in entries to SA Health’s adverse events records system, the Safety Learning System, between January 2015 and December 2017.
SA Health has not responded to requests to disclose the year in which the third person died. However, the unit was closed in December 2017 – suggesting the death occurred during that month.
“We are unable to comment on the circumstances relating to cases before the Coroner, but will assist the Coroner as required.”
The department closed the short stay unit to mental health patients in December last year after medical staff told a doctors’ union safety inspector that it was “only a matter of time” before a preventable death occurred there.
The report described the facility as “appalling” and “unsafe for both staff and patients” and warned that it featured a number of “extremely obvious ligature points” – features of a room that can facilitate suicide.
In 2016, Deputy State Coroner Anthony Schapel found that 43-year-old Geoffrey Noakes, who took his own life less than two hours after being discharged from the Lyell McEwin Hospital in February 2013, should not have been allowed to leave.
Schapel found his death might have been prevented if Noakes had been held at the hospital under an inpatient treatment order, rather than released.
Also in 2016, State Coroner Mark Johns found it was “completely unacceptable” that neither Jeremy Williams, 24, nor Robert Campbell, 53, were assessed by a psychiatric medical officer when they entered the Lyell McEwin Hospital on separate occasions in early 2012.
Both men died by suicide within days of release from the hospital.
“If that is the best the State’s mental health system can do it is difficult to find words sufficient to match the severity of the problem,” the Coroner said in his findings.
“It is a feature of the State’s mental health system that it is disjointed and lacks continuity of care.”
Johns was unavailable for comment.
The new documents, released to Greens MLC Tammy Franks under freedom of information laws, show two instances in which mental health patients were discharged without proper process.
One patient, described as being at “high risk” of self-harm, was discharged from the service with “no further follow up” last year, the documents say.
The person was “discharged – against short stay unit home team plan – (and) put at risk of harm to self with inadequate follow up”.
The entry says the patient was referred to youth mental health service Headspace.
But the referral was rejected because the patient was “high risk” – and there was no further followup.
“Headspace referral was submitted on discharge by on call team, however was rejected by Headspace due to high risk of patient.
“No further follow up was put in place by on call team, placing the patient at significant risk.”
Another patient was released from the service without a discharge summary, without details of the patient’s GP and without a known home address.
The incident was described as a “failure in referral process”.
“Consumer could not be contacted via phone and address for home visit unknown,” the entry reads.
“Also no GP details listed and no discharge summary completed.
“Discharged from service.”
It is unclear what happened to the two discharged patients.
A spokesperson for SA Health told InDaily discharge planning was “a complex process tailored to the individual patient, with the final decision made by clinicians in consultation with patients and their families”.
“Our clinicians and staff are appropriately skilled and undergo vigorous professional development and mandatory training requirements to ensure patients are discharged at the most clinically appropriate time,” the spokesperson said.
Franks urged the government to prioritise and adequately resource its suicide prevention efforts.
Last month, the Government announced it had appointed Liberal MLC John Dawkins to lead the Premier’s Council on Suicide Prevention.
“The suicide prevention taskforce’s work is vitally important and needs to be given priority and resourcing,” Franks said.
“My heart goes out to the families of those whose loved ones were lost because they couldn’t get the help they needed in the timeframe they required it.”
If this article has raised issues for you, you can call LifeLine on 13 11 14 – or you can call the Mental Health Triage Service / Assessment and Crisis Intervention Service on 13 14 65.
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