‘This should never have happened’: Why almost 100 admissions only made Bec sicker
Gitta Mueller and Doug Sewell remember their daughter, Bec, aged 19, tearful and sitting in the sun outside Manly Hospital. They were completely naive about the distorted world they would enter for the next 14 years.
Bec was a bright spark; exceptionally creative, with the palest blue eyes. She felt deeply, loved fiercely. Among those who loved her back were her parents, three sisters and her loyal girlfriends. She had also begun to have disturbing thoughts.
Doug Sewell and Gitta Mueller said the mental health system failed their daughter Bec Mueller Sewell.Credit: James Brickwood
“There was some mention of hearing voices,” Mueller recalls Bec’s friends expressing concern. “But we didn’t know what that meant. We had no experience with mental illness.”
After a GP recommended Bec seek a psychiatric assessment, a psychiatrist at Manly Hospital offered to keep Bec overnight for observation. Her parents told her they would return to take her home in the morning.
“Instead, they locked her up,” Sewell said. “That’s when everything went completely out of control, and we were harshly introduced to a deeply flawed mental health system.”
Bec had been sectioned as an involuntary patient under the Mental Health Act. It was shocking for Bec and her parents, but Bec was no outlier. More than half of admissions to NSW mental health units involve involuntary treatment.
Mueller and Sewell weren’t told why. Hospital staff cited patient confidentiality: Bec was an adult.
Four weeks later, Bec’s treating psychiatrist discharged her, telling Mueller hospital was the wrong place for Bec. She was getting worse.
This was the first of almost 100 hospital admissions – involuntary, voluntary, emergency, mental health wards, eating disorder units and medical wards – as Bec’s illness and trauma intensified.
On May 19, 2024, while on a trial leave weekend from Westmead Hospital, Bec took her life. She was 33 years old.
“Bec’s treatment failed her, not because of the complexity of her illness alone but because there was nowhere she could find as a safe, therapeutic place to recover and be understood,” Sewell said. “This should never have happened.”
Specialised mental healthcare can be life-saving. But Bec’s story is an extreme, though not rare, case of the “Homeric odyssey” people with complex mental illness face in NSW’s fractured, chronically under-resourced and overwhelmed mental healthcare system, which can inflame the diseases it aims to treat and inflict fresh wounds.
Peak mental health bodies criticised last week’s federal budget for ignoring people with complex mental health conditions, with $44 million for headspace, a service for less acute patients, but no meaningful investment to address workforce shortages.
“The wholesale application of the medical model of the health system to mental health has failed,” said clinical psychologist Professor Sarah Maguire, director of national eating disorder research organisation InsideOut.
“Patients and their families have been telling us that for a long time, and the mental health workforce has been saying that with their feet.”
The protracted public psychiatrist workforce shortage and bitter dispute between specialists and the state government led to mass resignations this year.
A ‘bargain-basement’ model
Iatrogenesis – when treatment itself causes or compounds harm to patients – has been discussed with increasing frequency among mental health clinicians, researchers and policymakers.
Professor Pat McGorry, psychiatrist and executive director of youth mental health organisation Orygen, said iatrogenic harm was a direct result of chronic neglect of the mental health system that was now “absolutely terminal”.
Professor Pat McGorry, director of Orygen, Centre of Excellence in Youth Mental Health.Credit: Aaron Francis
“We have replaced the old, institutionalised asylums with a bargain-basement model of care that offers patients a hopeless picture of their future,” McGorry said. “Young people in the early stages of illness are on locked wards with people who have long-term, severe mental illness.”
McGorry said patients were subjected to a revolving door of admissions and discharges in institutions more concerned with risk management than therapeutic care and early, evidence-based interventions.
“It is an incredibly debased system of care,” he said.
No safe haven
Bec was kept in locked wards with older, physically imposing men who were aggressive to staff and other patients. Mueller recalled one patient who shattered every panel of a mental health unit’s glass wall. Bec was physically restrained by staff several times, Mueller said, remembering one distressing incident when she was taken, screaming, to a padded seclusion room.
Bec told her parents she was sexually assaulted by another patient during one admission and discharged as a result.
She was shunted from private psychiatric hospitals to public emergency departments for expressing thoughts of harming herself, so she stopped disclosing her thoughts.
“There were times she was completely mute,” Doug said. “She was terrified.”
Bec was labelled “non-compliant”, “treatment resistant” and “attention seeking”, which only reinforced her helplessness, Sewell said.
She once tried to run from an emergency department and was dragged back by security guards.
University of NSW conjoint professor of psychiatry Matthew Large said the Homeric odyssey through the mental health system often began with the “Trojan Horse” of voluntary treatment, only to become an involuntary patient.
The system’s risk mitigation focus led to more restrictive practices, said Large, even though stigma, trauma and social isolation – common consequences of inpatient (particularly involuntary) admissions – are known risk factors for suicide in the community.
“Why wouldn’t these factors also be potent drivers of suicide among our already more vulnerable patients?”
NSW Chief Psychiatrist Dr Murray Wright denied that “resource challenges” led to poor services.
“The services do a very good job under difficult circumstances, and we work really hard to maintain that level of effort and support the services where they’re particularly under pressure,” he said.
NSW Health Chief Psychiatrist Dr Murray Wright. Credit: Dominic Lorrimer
Wright said NSW Health had a system directed at minimising the potential harm when someone is unwell enough to be admitted, particularly involuntarily.
“I know we can improve, I know that there are cases where the outcomes are not good, and we don’t shy away from that,” Wright said. “We investigate and try to learn from them, but I don’t want those to overshadow what for a very significant number of people can be a positive and, indeed, life-saving experience.”
In 2024, there were roughly 2.8 million community mental health contacts and about 40,000 inpatient admissions in NSW’s public mental health system.
Seclusion and restraint in NSW hospitals
NSW Health monitors and publicly reports the use of seclusion and restraint in mental health units, which, Dr Murray Wright says, are a useful proxy for understanding a service’s culture of restrictive practices.
In the December quarter last year, 3.5 per cent of mental health admissions involved the patient being put in seclusion. The average seclusion duration was six hours and 53 minutes, 3 hours less than the same quarter in 2023.
Apart from the Forensic Hospital (with an average seclusion duration of 25 hours 17 minutes), seclusion time ranged from 16 hours and 46 minutes at a Cumberland Hospital to zero in eight mental health units, including Westmead.
The percentage of acute mental health episodes of care with at least one physical restraint event in NSW was 4.9 per cent for an average time of four minutes.
The medical-mental health divide
Bec’s parents believe her eating disorder was partly a response to the trauma of her first hospitalisation.
“She said she wanted to disappear and stopped eating,” Mueller said.
For every subsequent admission, Bec’s anorexia became the prism through which all her pain was refracted.
Gaining weight was the treatment target. Her psychosis was secondary if treated at all. The nasogastric tubes and forced IV lines on medical wards were agonising for Bec, who believed the nutrients were poison coursing through her veins.
Maguire said this case was an honest reflection of what can happen to people with complex presentations.
“There are very few places, if any, in the system that can meet the person where they are at,” Maguire said.
At a private clinic, Bec lasted four days under the care of a psychiatrist who, months later, was convicted of sexually assaulting multiple patients.
At another private hospital, a fellow patient escaped and took their life at a railway station.
“Bec told us that she wished it could have been her,” Mueller said.
Sloppy prescribing
With almost every admission, Bec had a new doctor and drug regimen of anti-psychotics, sedatives and antidepressants, some causing nightmarish hallucinations and extreme agitation.
McGorry said no continuity of care led to “sloppy, irrational prescribing” and patients medicated at doses to control behaviour rather than treat illness. Wright strongly rejected the characterisation of inappropriate prescribing as “sloppy”.
“Psychiatrists are trained to work holistically, to connect with a person, and convince them that you are there to help them,” McGorry said. “But the environment doesn’t allow for this.”
“We have replaced the old, institutionalised asylums with a bargain-basement model of care that offers patients a hopeless picture of their future.”
Professor Patrick McGorry, psychiatrist and executive director of youth mental health organisation Orygen
Senior consultation-liaison psychiatrist Dr Lauren Taylor briefly treated Bec when she led Westmead Hospital’s medical psychiatry unit, the only unit in NSW providing integrated psychiatric and supportive medical treatment.
“People with serious mental illness die 10 to 20 years younger. There is a total lack of integration, a massive dividing fault line separating medical and mental healthcare. It is utterly archaic.”
Taylor, who resigned in November 2024, was the first to mention “iatrogenic harm” in Bec’s case.
“In complex illnesses, you have to be clear-minded about iatrogenic harms and the risk-benefit analysis in a patient-centred manner,” Taylor said.
“One can never know, but I wonder if the prospect of returning to the system that had systematically failed her … in addition to her torturous, gruelling symptoms contributed to her decision [to take her life].”
Taylor said under-resourced staff were managing overwhelming numbers of severely unwell patients and struggling to discern the most therapeutic, least coercive treatment.
NSW Minister for Mental Health Rose Jackson said in a statement: “Protecting continuity of care for our most vulnerable patients remains the top priority, alongside efforts to strengthen services and deliver meaningful reform.”
Jackson said help is available, and comprehensive contingency plans are in place to ensure those seeking mental health support continue to receive the care they need.
‘Tantalising’ ways forward
Bec’s parents are advocating for changes that would have made a world of difference for their daughter: A comforting, lounge-like setting for people in mental distress presenting to hospitals, timely processes to bypass emergency when possible, and publicly funded, trauma-informed inpatient clinics that integrate mental illness and eating disorder treatment.
McGorry said federal and state governments must commit significant funding increases to support early intervention, hospitals-in-the-home and social services, including supported housing and vocational recovery interventions.
“It’s tantalising because you know that things could be so much better if these approaches were embraced,” he said.
Good programs exist in pockets of the health system, Maguire said. Work under way to redesign the system focuses on personalised interventions, engaging with services within and outside the hospital to meet the patient’s changing needs throughout their illness.
Critically, any new intervention must be continually evaluated, Maguire said, acknowledging the evidence base for treatment was developing “at best” and patients needed to be asked how they felt receiving treatment, and give input into its design.
“Some of what we deliver is not tolerable for patients, some may be harmful, but we must keep collecting data,” she said.
A whole-of-government suicide prevention legislation is expected to be introduced to parliament this year following a statewide mental health gaps analysis to guide improvements.
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