Ms S

CORONERS COURT OF QUEENSLAND FINDINGS OF INVESTIGATION CITATION: Non-inquest findings into the death of Ms S TITLE OF COURT: Coroners Court

JURISDICTION: SOUTHPORT DATE: 22/03/2024 FILE NO(s): 2021/2621 FINDINGS OF: Jane Bentley, Coroner CATCHWORDS: CORONERS: suicide; post-natal depression; lack of perinatal mental health beds; mother baby mental health inpatient treatment.

Table of Contents Background 1 Investigation 1 - 4 Conclusions 4 Findings required by Section s45 4

Ms S lived with her husband. She suffered from post-natal depression after giving birth some eight weeks before her death. She was an inpatient at the Logan Hospital Mental Health Unit from 8 to 11 June 2021 At about 9.15am on 12 June 2021 Mr S gave Ms S her medication and then left the house to get some mower fuel. Ms S was in bed. Their baby was asleep in another bedroom.

Mr S arrived home about 25 minutes later and called out to Ms S. She did not reply. He then went into the main bedroom and found her hanging from a bathrobe belt which had been tied around the shower frame in the ensuite bathroom. He immediately cut her down, called 000 and commenced CPR.

Police officers arrived within six minutes of the call and took over CPR. Queensland Ambulance Service paramedics attended, continued CPR and transported Ms S to Logan Hospital. Ms S was found to have sustained unsurvivable brain injury. Her family made the generous decision to donate her organs and that procedure was carried out on 14 June 2021 and Ms S was then pronounced deceased.

The Metro South Addiction and Mental Health Service Ms S had received mental health support from the Metro South Addiction and Mental Health Services (MSAMHS) from 17 December 2020 to 12 June 2021.

On 17 December 2020 Ms S was referred to the MSAMHS Perinatal Wellbeing Service by a registered midwife due to her increased anxiety in pregnancy, particularly relating to birth and motherhood.

The Service attempted to contact her on 12 January 2021 and were unsuccessful in obtaining phone contact so sent her a letter and closed the referral.

Ms S went into labour on 11 April 2021 and had a natural birth assisted by forceps. Her baby was tongue tied which resulted in difficulties with breast feeding which, it was noted, “caused [Ms S] considerable distress.” Ms S was discharged from the Maternity Inpatient ward on 14 April 2021 and her postnatal depression risk factors were documented as “nil, supportive family.” Ms S was seen by a community midwife on 15, 16, 22 and 27 April 2021 and no mental health issues were noted.

Ms S presented to the Logan Hospital Emergency Department on referral from her GP on 2 June 2021 with anxiety, insomnia and suicidal ideation. She was experiencing poor sleep and her baby was difficult to settle. It was noted that these factors had increased her anxiety and worsening mood over the past weeks and she had experienced a panic attack the night prior to her ED presentation.

The MSAMHS carried out a review of the circumstances of Ms S’s death and her contact with the Logan Hospital Mental Health Inpatient Ward.

The review team noted:  The various suicide risk screening tools utilized by Qld Heath were not specific to a patient who was experiencing stressors associated with the care of a newborn and did not have a specific postnatal focus.

 The current risk assessments-suicide prevention pathways used by various Qld Mental Health services do not have a specific postnatal focus for patients who present with suicidality and there should be consideration undertaken as to incorporating this into the development and evolution of Suicide Prevention Pathways.

The review team stated that the MSAMHS was rolling out service wide “Engage Assess, Respond & Support” training as part of service-wide implementation of the Zero Suicide in Healthcare framework which will be provided to all MH clinicians and therefore no further recommendation was required.

The review team noted that Ms S was referred to numerous services to support her in the community and she expressed feeling like she was just being referred onto a number of services and appeared to be overwhelmed by this process. The team opined that this should be discussed at meetings in the future.

The review team acknowledged that the MSAMHS has limitations in infrastructural capabilities of accommodating women and children to support the care and treatment of postnatal depression in an environment that is tailored to their needs. The team also acknowledged that MSAMHS clinicians appeared to have limited understanding of the scope and specific criteria for acceptance associated with referral to the Perinatal Wellbeing Team of the MSAMHS.

Findings into the death of Ms S 1

The review team concluded:  Overall, the care provided to Ms S was appropriate.

 The team was unable to identify any practitioner factors or significant system issues which directly contributed to her death.

 The team recommended that the Qld Health Mental Health Branch review access to specialty services and options of care for patients presenting with mental health conditions in the postnatal period.

The Queensland Maternal and Perinatal Quality Council reviewed the circumstances of Ms S’s death and in March 2022 concluded.

 Ms S had severe postnatal depression.

 She and her family made every effort to seek appropriate care given their resources.

 Every effort to provide appropriate medical care was made, given the resources available to treating clinicians and teams.

 Ms S required an inpatient admission.

 A lack of public mother and baby beds to treat women with severe postnatal depression contributed to Ms S’s death.

 Had there been a mother and baby bed available such as is provided at the Lavender Unit in the Gold Coast, Ms S would have likely received appropriate care and her death would most likely have been prevented.

The Council noted that there were only four public mother baby beds situated at the Gold Coast University Hospital. Each year there are approximately 60,000 births in Qld and almost 1000 mothers with children under 12 years present to emergency services in a suicidal crisis. Each year, nearly 10,000 women require primary care for perinatal mental health issues, 3,000 require specialist psychiatric treatment and over 200 require hospitalisation.

The recommended ratio of mother and baby beds is 1:1500. In Qld the ratio was 1:14,879 births. Victoria had a ratio of 1:2261 beds per birth.

The Council concluded that women die, leaving babies without mothers, if appropriate inpatient mother and baby facilities are not available.

On 24 May 2022 the Chief Psychiatrist, Mental Health, Alcohol and Other Drugs Branch of Qld Health advised:  Qld currently has four public (statewide) mother-baby mental health beds (The Lavender Unit) based at the Gold Coast University Hospital established in 2017.

 Investment to support this plan is subject to the State Budget process.

 Perinatal mental health, including the need to increase access to specialist inpatient and community mental health care during the perinatal period, is a key priority.

 Mater Health is developing a new Mater Family Wellbeing Service which includes a new inpatient Mother Baby Mental Health Unit (Catherine’s House).

 The Mater Foundation has raised $14 million towards the capital costs of the refurbishment of the Convent for this service.

 Mater Health has advised it will operate a number of these inpatient beds as private mother/baby beds.

 Queensland Health is engaging with Mater Health around the provision of up to eight public beds in this new Unit.

 If funding is approved through the State Budget process, it is anticipated Catherine’s House eight public mother-baby beds will commence services in late 2022.

 Queensland Health’s planning processes have also identified the need for additional state-funded mother-baby beds in Northern Queensland, with future capital processes expected to provide additional bed capacity in the region.

 On 8 September 2022 Qld Health advised that the analysis was provided to the Chief Psychiatrist, Mental Health, Alcohol and Other Drugs Branch (MHAODB) of Qld Health who advised that the Findings into the death of Ms S 2

MHAODB would be considering the following recommendations:  Suicide prevention pathway (SPP): Review and consider tailoring for perinatal setting.

 Engage, assess, respond to and support a suicidal person (EARS) training: review and consider tailoring for the perinatal setting.

 Targeted assessment of depression in the perinatal period.

 Availability of perinatal mental health beds including strengthening arrangements to network and optimise the use of public and private bed capacity to meet emergent needs.

On 15 December 2023 Qld Health advised that there are now 12 public Mother Baby inpatient beds in Qld:  Lavender Mother and Baby Unit (Lavender MBU)– 4 public beds located at Gold Coast University Hospital o The unit provides specialist care for women and their babies if the mother has significant mental health problems such as severe depression, anxiety, or a psychotic illness such as bipolar disorder, schizophrenia, or postpartum psychosis who cannot be safely managed in the community. The unit is supported by the Lavender Perinatal Mental Health Community Team who will assess and triage referrals to the Lavender unit and facilitate discharge back to the referring service. Where a referral is cannot be accepted, the team provide consultation and liaison to develop a treatment plan and/or referral to local services.

 Catherine’s House Inpatient Unit (Catherine’s House) – 8 public beds located at Mater Mother’s Hospitals South Brisbane Campus o This unit is Queensland’s first integrated perinatal mental health centre providing: o Catherine’s House Inpatient Unit - Specialist in-patient care for women and their babies if the mother has significant mental health problems such as severe depression, anxiety, or a psychotic illness such as bipolar disorder, schizophrenia, or postpartum psychosis who cannot be safely managed in the community. The facility also provides an opportunity for rooming in of partners as appropriate.

o Parent Support Centre for mothers and babies up to six months after birth.

o Parent Aide Unit a home visiting service with trained volunteers to help improve infantparent relationships.

o Day Programs Public and Private individual and group therapy treatments.

o Individual Consultation Catherine’s House has a range of public and private practitioners for consultation.

 Private Mother Baby Units in Queensland also include: o Brisbane Centre for Postnatal Disorders – 10 beds located at Belmont Private Hospital; o Catherine’s House (private component) – 2 private beds located at Mater Mother’s Hospitals South Brisbane Campus; o Public Mother Baby Units in Queensland are state-wide services. Referrals to the Lavender MBU and Catherine’s House Inpatient Unit are managed state-wide. This is informed by available beds (Lavender MBU - 4 beds and Catherine’s House - 8 beds), locality of admissions, consideration of existing bed flows and consumer preference.

Admissions from any catchment will occur at either mother baby unit following review of bed availability and driven by consumer needs; o Additional Mother Baby inpatient beds in Townsville and Sunshine Coast are an identified project in the Queensland Health Q32 pipeline for priority progression and future investment. It is anticipated that planning for these areas will commence in 2024.

Findings into the death of Ms S 3

Conclusions I find that Ms S died from hypoxic ischaemic encephalopathy, due to hanging. Her death was due to suicide in the context of severe postnatal depression. Her death may have been prevented if an appropriate mother baby inpatient admission had been available to her. The current number of such facilities in Qld remains about ten times below the recommended ratio.

Findings required by s.45 Identity of the deceased – Ms S How she died – 1(a) Hypoxic ischaemic encephalopathy, due to 1(b) Hanging Place of death – Logan Hospital LOGAN CENTRAL QLD 4114 AUSTRALIA Date of death– 13 June 2021 I close the investigations.

Jane Bentley Coroner 19 March 2024 Findings into the death of Ms S 4