Teenager made suicidal, homicidal admissions before taking her life, Coroners Court hears

In the weeks before she took her own life, a teenager was taken to hospital multiple times saying she planned “to harm herself and others” but was never admitted to psychiatric care, a court has been told.

The Coroners Court of Victoria will probe clinical care decisions made by medical staff in the lead-up to a teenager’s suicide. Picture: Steve Tanner

A teenage girl made repeated suicidal and homicidal admissions to medical providers but was never admitted into psychiatric care in the lead-up to her suicide, a court has heard.

The girl, who cannot be identified for legal reasons, took her life at her home following a deterioration in her mental health during the Covid pandemic.

An inquest into her death by the Coroners Court of Victoria will probe clinical care decisions made by medical staff, as well as “systemic issues” related to the state’s emergency call service.

In the weeks prior to her suicide, the teen was taken to hospital on multiple occasions but never admitted to psychiatric care.

This was despite her on one occasion telling paramedics on route to hospital that she had “plans to harm herself and others”, the court heard.

That clinical decision was made because the teen did not meet the hospital’s “criteria for involuntary admission”, according to a court summary.

Four days later, the teen was again returned to the hospital in an ambulance.

The court heard that despite again threatening to kill herself, a psychiatric nurse did not admit her into care.

The court heard the girl disclosed to a triple-0 operator that she planned to end her life.

The teen’s grieving father believes “more could have been done” to prevent his daughter’s death.

“In the months leading up to her tragic death, she was clearly in crisis. She was experiencing suicidal and homicidal thoughts and acted on them,” said Craig Eberhardt KC, acting on behalf of her father.

“With the assistance of her mother, police and paramedics, she repeatedly engaged with mental health professionals and, on more than one occasion, was requested to be admitted to hospital but she was never admitted.

The lawyer said the girl’s father remained “very upset and very distressed about the circumstances of his daughter’s death”.

“He wants to know what happened, why the decisions were made and whether or not, most importantly, lessons could be learnt to prevent what he and his wife are going through,” Mr Eberhardt said.

The girls’ parents reported a swift decline in her mental health during the Covid pandemic as classes were moved online.

The girl disengaged from school and later physically harmed herself and her mother.

The day of her death she called triple-0, asking to be connected to Ambulance Victoria.

The court heard she disclosed to the call taker she was holding a blade and planned to end her life.

Four minutes later, a “police event” was generated due to the teen’s admission that she was armed.

Three minutes later, she was transferred to the Ambulance Victoria triage service, which picked up about two minutes later.

The call was then terminated by the teen.

The court heard had the teen nominated police rather than paramedics at the outset of her call, the emergency response would likely have been faster.

Paramedics require police attendance at scenes where there is a threat to safety, such as weapons.

Coroner Sarah Gebert told the court it was a “systemic issue” that would be probed during the inquest.

“If (she) had elected to speak with police, the call would have been given a different priority,” Ms Gebert said.

“I can see that some police members were able to get there within five minutes.

“This appears to me to be a fundamental issue with what someone might elect who doesn’t know what’s appropriate. As soon as she says there is a weapon, the ambulance can’t really attend until police do.”

The inquest will take place later this year.