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A lost map, an ‘early’ discharge and a tragic death in Adelaide’s south


An Adelaide public health facility that discharged a young man three days before he killed himself also misplaced a suicide note and a map, which his mother believes could have saved his life.

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The young man, identified only as ‘J’, took his own life in early April this year, three days after being discharged “too early” from Morier Ward at Noarlunga Hospital, in Adelaide’s South.

The tragic circumstances surrounding his death are detailed Principal Community Visitor Maurice Corcoran’s annual report, tabled in parliament yesterday.

His treatment at Morier Ward was J’s second acute mental health admission for extreme anxiety following a suicide attempt.

He was admitted in similar circumstances around Christmas time last year, after which the treating team had asked his mother to try and find his prescription medication.

She found the medication hidden in a draw, along with a suicide note and a map, indicating where he could be found if he goes missing.

She handed the medication to the team along with the documents, stressing that they were important, and she wanted them back.

When J was readmitted to the facility just before Easter this year, she asked for the note and the map back, but never received them.

She recalls a staff member telling her to “make sure you keep a close eye on him,” suggesting he was still very unwell and at risk of self-harm when he was discharged on Easter Sunday.

Returning from a brief trip to the shops two days later, she found that J had disappeared from the house.

She rang the treatment facility and was immediately urged to phone police.

J’s body was found the following day.

The mother told Corcoran that “if she still had the suicide note, map and diagram, when he went missing, she may have been able to inform the police where J was going and possibly found him before he ended his life.”

“This has compounded her grief and loss,” Corcoran’s report reads.

J’s father told Corcoran he believed his son had been “a victim to … pressure on doctors to discharge clients early, and when they may need more time in care, if they are still unwell, in this case due to anxiety and (the) risk of self-harm”.

Earlier this year, Corcoran published a report warning that a 24-hour time limit placed on hospitals admitting mental health patients was having “downstream” consequences, including “pressure to release patient early to create a bed for patients in the ED” and “bed allocation being based on bed flow priority, not clinical need”.

In May, the month after J’s death, a psychiatrist from the South contacted Corcoran to express concerns about discharge pressure.

“The psychiatrist highlighted a range of examples where he, and colleagues he named, believed it placed clients at high risk,” the report reads.

Corcoran has written to state Coroner Mark Johns, asking him to investigate J’s death. He has yet to receive a response.

Also in May, the parents met with J’s treating psychiatrist – who is not identified in the report – along with Clinical Director of mental health in Adelaide’s South, Professor Malcolm Battersby.

The treating psychiatrist detailed how he made the clinical decision to discharge J after the short admission, the report says.

In June, Southern Adelaide Local Health Network chief executive Susan O’Neill wrote to Corcoran responding to a series of questions about J’s death.

“Regretfully I am advised that the notes and diagrams have not been located and that staff are still actively trying to locate them,” O’Neill writes.

“I can assure you that if these documents are found we will return them to J’s mother as a matter of high priority.”

This year, InDaily has revealed a raft of problems in mental health services in Adelaide’s south, including a leaked external review which uncovered “sub-standard systems”, staffing shortages and poor planning.

Corcoran told InDaily this morning that J’s family needed answers.

“The family really want this looked into, to get answers and try to learn from what happened, so it doesn’t happen to other individuals and families,” he said.

Corcoran said he hoped that early, unsafe discharge had not been responsible for any deaths in Adelaide, but that there was anecdotal evidence that the focus on “bed flow” was increasing the proportion of patients returning to hospital soon after being discharged.

He said clinicians feel increasing pressure to release patients quickly because of the ongoing overcrowding crisis in the state’s hospitals.

“There are pressures across the system, generally (and) in mental health,” said Corcoran.

“I feel for (clinicians) who have got to make these decisions on a daily basis.

“It must be incredibly difficult and complex.”

A spokesperson for SA Health said J’s case would be comprehensively reviewed as part of a wider review into mental health care in the Southern Adelaide Local Health Network.

In a statement, the spokesperson said: “The wellbeing and recovery of patients is our number one priority and individualised discharge planning takes into account a range of clinical matters, risks, social and family factors to optimise the patients’ chances of recovery.”

The SA Health Mental Health Services Plan currently being prepared by the Chief Psychiatrist and SA Mental Health Commissioner will critically look at continuity of care, safe discharge planning and adequate follow-up to ensure we deliver the best possible outcomes across inpatient and community mental health care.”

InDaily has contacted Coroner Mark Johns for comment.

If you or someone you know needs help, contact Lifeline on 13 11 14, the Suicide Call Back Service on 1300 659 467, Kids Helpline on 1800 55 1800 or MensLine Australia on 1300 789 978.

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