Australian Doctors’ Fund Blog

Lives Worthy of Life: Website Dedicated to Ending Preventable Deaths in Mental Health

July 8th, 2009

Interesting notes from:

• http://livesworthyoflife.com
• http://livesworthyoflife.com/index.php?page=cover-ups

Under pressure from various groups, the NSW government set up the ‘Sentinel Events Review Committee’ in 2003. Its construction was far from ideal, in that its Orwellian name isn’t one that the general public would realise covers mental health deaths – suicide and homicide.

The Committee also operates in strict secrecy – its members are anonymous; and under threat of several months’ imprisonment or a $40,000 fine if they say anything about its operations. Its report also goes to the Minister for Health rather than directly to Parliament, so he can sit on it until a time when it’s unlikely to create the intense shame and embarrassment for the government that its contents normally would. The then Minister released the first report on 23rd December 2003; and the next one in March 2005; after which the Committee’s appointments were not renewed until July 2006.

The next report, due in March 2006, could not therefore be completed until December 2006. The Committee would have been reluctant to give the Minister the opportunity to release it on 23rd December again, so won’t be giving it to him until after the holiday season. A bet on his not releasing it until after March 24th would be a very safe one, since the death rate has undoubtedly increased even further, and is now up to 4 a week – nearly all young; and nearly all preventable. There is a rumour that if re-elected, the Government intends to abolish the Committee.
The report - ‘Tracking Tragedy’ was eventually released on 19th October 2007, dated ‘May 2007′, the Health Minister having been sitting on it for six months, while presumably another 60 or more people died. You can access the report on the NSW Health website -  http://www.health.nsw.gov.au/pubs/2007/tracking_tragedy_07.html.

The following is an excellent summary article on it from the Daily Telegraph.

Murder, suicide up

October 20, 2007 12:00am

THREE mental health patients committed murder after not receiving adequate treatment, an alarming State Government report reveals.
The report also revealed the shocking details of two children killed by mental health patients. The NSW Health Tracking Tragedy report, which examined suicides and homicides that occurred shortly after hospital discharges, was slipped quietly through Parliament yesterday.

The report admitted inadequate bed numbers “may have led to premature discharge of three persons who later committed homicide.” And the NSW Mental Health Sentinel Events Review Committee reported that eight cases involved the killing of a family member or friend of the patient.

The report revealed one woman in her 40s killed her child just two days after being in contact with mental health services. Another male in his 20s killed a close friend three days after seeing a mental health professional and a schizophrenic man in his 40s killed a close friend one day after being in touch with the NSW Health.

Health professionals on the committee condemned the current system, saying a review of 113 patients who suicided found 59 per cent of them received only cursory treatment. In about 50 per cent of cases the suicidal client was identified as a parent - but child safety was not investigated.

The key findings of the review of homicide cases found not all referrals by courts for psychiatric assessment were adequately reported and said “inadequate follow up, clinical care and support of some high risk patients of mental health services led to fatal consequences”.  “Two of the nine cases analysed involved the deaths of children,” the report read.  “Three cases were homicides associated with suicide or attempted suicide.  Eight cases involved the killing of a family member or close acquaintance.”

The findings follow the 2005 Tracking Tragedy review on the mental health system that found that, between 1993 and 2001, 1153 patients committed suicide after they were refused treatment or discharged.  A number of recommendations were implemented. Yet, 12 months later, the 2006 report card portrays a crumbling system.

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