The supervision, treatment and care of a severely depressed Perth woman before she flew to Mexico and committed suicide was not optimal, but was not below accepted practice at the time, a WA Coroner has found.
The 39-year-old woman, known as Ms D, travelled to Mexico in April 2008 after she discharged herself from King Edward Memorial Hospital earlier that month and was placed on a community treatment order.
She had been made an involuntary patient in February but her involuntary status was later removed by the Mental Health Review Board despite hospital staff having found evidence of her suicide plan.
A coronial inquest into her death was held earlier this year.
In findings handed down today, acting State Coroner Evelyn Vicker found the woman, who was deeply resistant to conventional medication and hospitalisation, "well knew how to mask her real presentation with a facade of seeming to comply with treatment".
Ms Vicker said the woman used a hearing before the MHRB "to convince the members she was quite rational and able to make appropriate choices for her wellbeing".
Ms Vicker said: "She effectively convinced the MHRB she would be better off without the restrictions imposed by her involuntary status".
Ms Vicker said the decision to allow the woman to be treated in the community was "entirely understandable".
The inquest heard the woman withdrew consent for her sisters to be provided with information and the sisters felt that if they had not been so excluded, "they would have been in a position to intervene successfully in the deceased’s suicidal ideation for long enough to get her through the crisis around her death into a safer space".
Ms Vicker said the woman would have understood it was very unlikely her treating clinicians would have involved her sisters due to their perception it would affect her progress.
"The competing tensions around patient confidentiality as they stand currently make it extremely difficult for those involved in an involuntary patient’s care to reconcile the conflict between sharing information with family members and their duty of care and the restrictions placed upon them by law, privacy issues and health services policies," Ms Vicker said.
Ms Vicker said there should be a requirement - reflected on both consent forms and in the notification forms to the Mental Health Review - for people acting in a person’s best interests to have them assessed for involuntary status to be notified of hearings where that patient’s involuntary status is reviewed.
Ms Vicker found the woman’s supervision, treatment and care while in the community was not optimal but "it would seem that was more due to the systems available for community supervision and resource issues, than a lack of care".
"There is nothing to suggest the care provided was below accepted practice at that time," she said.
"The systems in place have to allow for the fact that being constantly under supervision for some patients may be the catalyst which prevents their ability to recover at all and so survive in the community."
Ms Vicker said the Chief Psychiatrist undertook a review of the clinical issues which culminated in Ms D’s death and made eight recommendations with respect to improvements in the policies and procedures for the Mother and Baby Unit and nine recommendations to improve the Clinical Supervision of Community Treatment Orders supervised by the Alma Street Centre.
"I am satisfied both facilities have appropriately responded to the Chief Psychiatrist’s recommendations and implemented them where possible," she said.
"Unfortunately it is my view, on all the papers I have reviewed, the issue of clinical judgment as to the appropriate ways to breach a person with involuntary status’s confidentiality, and the decisions which are required to be made when the MHRB has changed the status of an involuntary patient still remain fundamentally unclear."* Readers seeking support and information about suicide prevention can contact Lifeline on 13 11 14 or the Suicide Call Back Service on 1300 659 467.