Coroner finds teenager should have been treated in hospital rather than at-home system

“His death is profoundly sad, but in my view it was regrettably foreseeable.” Tasmania’s mental health hospital-at-home service has been slammed following the suicide of a Hobart teenager.

Tasmania’s mental health hospital-at-home service has been slammed following the suicide of a Hobart teenager – who a coroner says urgently needed intensive, in-patient care to prevent his “regrettably foreseeable” death.

The 19-year-old died in April 2019 following a series of “deficits in his care and treatment” amid a string of suicide attempts, Coroner Robert Webster said in his findings published Thursday.

Mr Webster said Tasmania’s Mental Health Hospital in the Home program began in March 2019 – designed to help people in their homes who would otherwise be treated in an acute in-patient hospital setting.

Up to 12 patients at a time would receive home visits, between several a week to twice daily, plus phone check-ins from medical staff.

Mr Webster said part of the requirements for the program was that patients not be of imminent risk of harm to themselves or others.

He also noted patients experiencing active suicidal ideation could be considered suitable for at-home treatment if they had capacity to make decisions regarding their care, preferred to stay at home, and had supportive family or friends.

Mr Webster said the teen was enrolled in the program one week after it became operational, as its fifth participant, following a “significant and serious decline in his mental health” and following a suicide attempt at a northern suburbs school in March 2019.

The teenager was visited and called regularly at home while in the program, with his level of need downgraded over the course of several weeks.

On April 5, he attended the Royal Hobart Hospital after saying he did “not feel safe”.

However, the department was not aware of the Mental Health Hospital in the Home program, which might have allowed for fast-track assessment and possible admission.

In the early hours of the following morning, he was found at another northern suburbs school, having made another suicide attempt.

He was admitted to hospital, but a doctor released him from acute care and returned him to the in-home program.

Over the coming weeks, he attempted suicide several times before ultimately taking his life on a property behind a water tank – messaging his parents to not look for him, but to let police find him.

The coroner noted he’d had contact with at least 28 different in-home staff members during the month of April – and that the service had planned to discharge him despite his suicide attempts.

Mr Webster said the youth should never have been admitted to the in-home service, which was not fully operational, and that its care for him on April 5 was “inadequate”.

“In my view he required intensive inpatient treatment,” he said.

He said there were at least two occasions in which his participation in the at-home service should have been reviewed and terminated.

Mr Webster said the in-home service planned to discharge the youth despite several serious incidents, “with vague advice to contact a private psychologist”.

“Although it is not possible to speculate about whether the provision of inpatient care and treatment would have prevented (his) death at some point in the future … common sense suggests his survival, at least in the short term, would have been assured,” Mr Webster said.

“(His) death is profoundly sad, but in my view it was regrettably foreseeable given the deficits in his care and treatment.”

A spokesperson said the Department of Health conducted a root cause analysis following the teen’s death, with a number of changes since made to the at-home service, including changes to admission criteria when a person was experiencing suicidal ideation or self-harm.

They also said “significant reforms” had been made to child and adolescent mental health services in Tasmania, with suicide prevention elevated to a Premier’s priority.

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Originally published as Coroner finds teenager should have been treated in hospital rather than at-home system