Gold Coast youth mental health services face major probe after deaths
The Queensland Government has launched an investigation into Child Youth Mental Health Services on the Gold Coast following a number of teen deaths and claims of patient mistreatment.
The Queensland Government has launched an investigation into Child Youth Mental Health Services on the Gold Coast following a number of teen deaths and claims of patient mistreatment.
Health Minister Tim Nicholls said the state’s Chief Psychiatrist will begin a review of the current model of care, which will examine the administration, management and delivery of the Gold Coast’s Child and Youth Mental Health Services after concerning allegations were raised about treatment being offered.
“Every effort must be made to improve systems and to strengthen processes to mitigate preventable harm for these vulnerable patients,” Mr Nicholls said.
Chief Psychiatrist Dr John Reilly will conduct the investigation under section 308 of the Mental Health Act 2016, with Dr Paul Denborough, the director of infant child, youth and headspace at Alfred Health Victoria, leading the investigation.
It is due to report by February 28, 2026.
The investigation comes after The Gold Coast Bulletin published a series of stories highlighting serious issues within Queensland’s mental health system, including the death of Gold Coast teenager Giaan Ramsay, who took her own life just days after being discharged from the “short-stay” mental health ward where she had been kept involuntarily for almost nine months.
A number of former patients, their families and staff have come forward to speak of punitive and restrictive practices within the mental health system, such as compulsory admission under Treatment Authority orders, patients being kept in isolation, denying access to the outdoors and their phones, seclusion from contact with others, as well as exposure to excessive use of physical and chemical restraint.
A Gold Coast Health spokesperson welcomed the decision to review Gold Coast Hospital and Health Service’s Child and Youth Mental Health Services, “as requested by our chief executive Ron Calvert”.
“Mr Calvert contacted Queensland’s Chief Psychiatrist Dr John Reilly last month, seeking his expertise to ensure the service is delivering the highest possible standard of care to its consumers.
“We look forward to working with the review team.”
A Gold Coast Health spokesman has previously said it would be inappropriate to comment on specific cases under coronial investigation but said patients received evidence-based, trauma-informed care with strong clinical oversight.
They said involuntary admissions were only made by authorised doctors when a person with mental illness could not consent, was at risk of serious harm, and could not be treated in a less restrictive way.
The spokesman said all care was subject to rigorous review and external oversight, including by the Office of the Chief Psychiatrist.
System at ‘rock-bottom’
Former Mental Health Council of Australia CEO, co-director of expert suicide prevention and mental health consultancy ConNetica and adjunct professor John Mendoza said while he welcomed the investigation, it did not go far enough.
Professor Mendoza, whose nephew and godson Jeffrey Mendoza took his life in 2014, just 30 hours after being discharged from Gold Coast University Hospital, said it was not just youth mental health services and not just the Gold Coast, but mental health services across the state that required urgent attention.
He said since his nephew’s death, the system had only worsened, with Queensland now “rock bottom” in terms of mental health services in the country.
He said patients were scared to present for care because of how they would be treated in the system.
“Everyone has heard or has experienced issues like physical restraint, involuntary admissions, locked wards, and they do not want to subject themselves to that,” he said.
“So we’re driven by crisis. People will not seek care voluntarily so it escalates to police, then a Treatment Authority or Forensic Order, and they’re locked in. Meanwhile, the private system won’t take the most acute cases, nor will the community care teams because they are so underfunded, so the patients are left circling the drain.
“The bureaucracy of Queensland Health is very averse to addressing anything, it’s just constant crisis mode and pretending there’s nothing to see. But anyone with experience knows exactly what is happening.”
‘A dog receives better treatment’
Professor Mendoza, who quit his position as chief adviser on mental health to the Rudd government in 2010 over its inaction, said the same issues that effectively killed his nephew still existed, and if anything were worse.
He said his nephew battled a “wicked mixture of brain and mind disorders” following his service in the Australian Defence Force, and, in November 2014, his family called police after he spoke of taking his life.
Police placed Jeffrey Mendoza under an emergency examination order, and he was taken to the Gold Coast University Hospital for an urgent mental health assessment.
Professor Mendoza said his nephew died just 40 hours after being discharged from the emergency department at GCUH – wearing only a theatre gown, with no one notified and no care plan, just a prescription for valium script.
“A key contributing factor to Jeff’s death was the requirement that he consent to be placed in the acute psychiatric unit at GCUH. He had to voluntarily submit to being kept in a locked ward,” he said.
“His past experiences in other psychiatric units in Brisbane and Ipswich had added to his trauma and he was not going to be locked up. Yet he knew he needed somewhere to be safe. He specifically asked to stay at the hospital but not in the psychiatric unit.
“But that was not within the procedures, so despite being brought to the hospital under an Examination Order, which required examination by the Consultant Psychiatrist, he was discharged in under 20 hours and signed out by a trainee psychiatrist (a registrar).
“A dog hit by a car gets a better standard of care than what he did.
“And now it’s even worse.”
‘Failed at every level’
Professor Mendoza said the introduction of the Mental Health Act 2016 was meant to improve patient outcomes and protect their human rights, but instead had led to increased rates of seclusion, restraint, and compulsory treatment.
He said a leaked report commissioned by the federal government recommended redirecting more than $1bn in funding from acute hospital care to community-based mental health services in 2015, but 10 years later nothing had happened.
“We have failed at every level, federal, state and local. I do blame the previous Labor government for not examining and recognising these issues in the almost 10 years since the MHA 2016 was introduced before they lost power,” he said.
“But there is an incredible opportunity for the LNP to step up now and make some serious changes. The announcement of this investigation is a start, but there is so much further to go, because the system right now is harming patients and staff.
“There are so many leaving because morale is rock-bottom and they can see the damage being done to patients and they don’t want to be part of it. They are doing their best in a terrible system and they are being broken too.
“They don’t want to be tying patients down, punishing them, using coercive practices and mechanical restraints on the people they were taught and trained to help.”
Coronial investigations continue
Professor Mendoza’s comments come as police, the coroner, the Health Ombudsman and Gold Coast Health continue to investigate the death of Giaan Ramsay, who was the third teen to die after being treated at Robina Hospital’s mental health ward.
Her own family found her body just 200m from the door of the hospital on July 27.
The teenager had been under a compulsory treatment order at the hospital, despite her parents actively seeking treatment for their daughter at the time it was issued.
The Ramsays have claimed the issuing of the Treatment Authority had removed their child’s rights, as well as their own as guardians, to prevent, object or stop treatment they believed was harmful.
Police and the coroner are also investigating the death of 17-year-old Neve Chapman, who took her life on November 19, 2024 while she was under the care of Gold Coast Health and had previously been an inpatient at the hospital where she had previously been subject to a Treatment Authority.
Another youth, who the Bulletin has chosen not to name, who was also placed under a Treatment Authority at the hospital, took his own life shortly after discharge.
His mother made a submission to the Mental Health Select Committee saying she was unhappy with his treatment but unable to stop it, and believed it contributed to his death.
The coroner investigated his death but declined to comment further.
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