Queensland mum died due to lack of hospital resources, coroner finds

A critical shortfall of inpatient facilities for mothers and babies in Queensland contributed to the death of a new mum who took her own life while suffering from severe postnatal depression, a coroner has found.

Coroner Jane Bentley found the woman’s death occurred in the context of severe postnatal depression

A critical shortfall of inpatient facilities for mothers and babies in Queensland contributed to the death of a new mum who took her own life while suffering from severe postnatal depression, a coroner has found.

The state had 10 times less dual inpatient facilities than the recommended ratio when the Southeast Queensland woman tragically died eight weeks after giving birth in 2021.

In non-inquest findings handed down on Friday, Coroner Jane Bentley said 10 days before her death on June 12, 2021, the woman presented to the Logan Hospital Emergency Department with anxiety, insomnia and suicidal ideation.

“She was experiencing poor sleep and her baby was difficult to settle,” the coroner wrote.

“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.”

Less than a fortnight later, the woman took her life as the baby slept in another room when her husband briefly went out for less than half an hour to buy mower fuel.

The Queensland Maternal and Perinatal Quality Council review provided to the coroner revealed the recommended ratio of mother and baby beds was 1:1500, but in Queensland that ratio fell well short at 1 in 14,879 at the time.

Queensland Health says that ratio has since reduced to 1:1578 with 38 public and private beds now available.

“We know there is more to do to reach the Commonwealth’s recommended target of 56 beds,” the health spokesman said.

“Work is underway to deliver two eight-bed mother-baby units in Townsville and on the Sunshine Coast – taking the number of publicly-funded beds to 28 and total beds to 54.

“We are employing an extra 20 perinatal and infant mental health clinicians to work at some of our busiest hospital and health services, including Metro South, Mackay, Wide Bay, the Gold Coast and Darling Downs.”

The coroners noted comments from the maternal and perinatal council regarding the mother’s death that: “She and her family made every effort to seek appropriate care given their resources,” the council’s review of the tragedy found.

“Every effort to provide appropriate medical care was made, given the resources available to treating clinicians and teams,” the council’s review of the tragedy found.

“A lack of public mother and baby beds to treat women with severe postnatal depression contributed to (her) death.”

The coroner was told that each year, there are about 60,000 births in Queensland and almost 1000 mothers with children aged under 12 present to emergency services in a suicidal crisis.

Almost 10,000 women each year require primary care for perinatal mental health issues, 3000 require specialist psychiatric treatment and over 200 require hospitalisation.

“The council concluded that women die, leaving babies without mothers, if appropriate inpatient mother and baby facilities are not available,” the coroner wrote.

The woman was seen by a community midwife four times in the weeks after giving birth and no mental health issues were noted on her file.

A review of the woman’s death conducted by the Metro South Addiction and Mental Health Services (MSAMHS) concluded that the care provided to her had been “appropriate”.

It recommended that the Queensland Health Mental Health Branch review care options for patients presenting with mental health concerns in the postnatal period and noted that extra service-wide training was being rolled out as part of the ‘Zero Suicide in Healthcare’ framework.

“The review team noted that (the woman) 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 coroner wrote.

In a report to the coroner, Queensland Health advised that there were now 12 public mother and baby inpatient facilities in the state including four at the Gold Coast University Hospital and eight at the Mater Mothers Hospital in South Brisbane.

There are a further 12 private beds in Brisbane which take admissions from patients across the state.

“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,” the coroner wrote.

“It is anticipated that planning for these areas will commence in 2024.”

Coroner Bentley found the woman’s death occurred 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,” she wrote.

“The current number of such facilities in Queensland remains about ten times below the recommended ratio.”

After the coroner’s report was released on Friday, Health Minister Shannon Fentiman issued a statement sending her condolences to the woman’s loved ones.

“We know that the months following birth can be an incredibly difficult time for new mothers, with one in five experiencing postnatal anxiety and depression, she said.

“The government welcomes these coronial findings. They will help us to provide more supportive and compassionate care to new mothers who need it most.”

The minister said a range of measures had been announced to support the mental health of new parents, including an $89 million investment in the government’s Better Care Together plan.

“This is in addition to the $20 million announced in November last year to hire 20 more perinatal mental health clinicians and boost community-based support,” Ms Fentiman said.

The minister said since opening eight beds at Catherine’s House at the Mater last year, care had been provided to 80 new mothers.

“We are also working with the private sector, community organisations, and Hospital and Health Services to deliver even more perinatal mental health beds right across Queensland as part of our Health Big Build,” she said.