Source: Radio New Zealand
The family of a mental health patient who killed herself after being allowed to go home for Christmas was not aware of her suicide attempt a week previously.
Gabriella Kathleen Ann Freeland – known as Kate – died on Christmas Eve 2021 at her family home in Auckland, the day after her father picked her up from the psychiatric in-patient ward at Palmerston North Hospital.
In her findings, released on Monday, Coroner Janet Anderson found the decision to grant the 28-year-old leave was “unwise”.
“I also have concerns about the adequacy of the information provided to Gabriella’s father at the time of her discharge,” she wrote.
“Robert Freeland was not properly informed about the seriousness of Gabriella’s situation, and he was not provided with information that might have helped reduce the risk of her ending her life while she was on leave.”
Her brother Jared Freeland, who was the one to discover her body, said the family wanted Gabriella’s death to be a catalyst for positive change within the mental health service.
He told the coroner that Gabriella’s case was not an isolated incident, and he wanted to draw attention to the “parlous state of mental health services” in New Zealand, which he described as a “national disgrace”.
Gabriella was diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) as a child and treated with Ritalin, going on to complete a computer science degree at university.
Her mental state deteriorated from 2017, the year that her mother Lydia died of motor neurone disease.
She started drinking heavily, and her behaviour became increasingly erratic.
In mid-2020, she consulted several GP clinics and emergency medical centres about shortness of breath and other symptoms, which she feared could be caused by liver damage from alcohol.
Her symptoms were thought to be related to anxiety.
She left Auckland in August 2020 without telling her family, who reported her as a missing person.
It is believed she was living “itinerantly” when she was discovered by police in early June 2021, carrying several items that could be used for self-harm.
After being assessed by an acute mental health team she was discharged from care the following day because she had declined help and did not meet the criteria for compulsory treatment under the Mental Health Act.
However, the next month she was admitted to Palmerston North Hospital mental inpatient unit after being arrested for “train hopping” on top of moving carriages.
She had knives and other items in her possession, and admitted she was suicidal and had made other attempts to end her life.
“She was dishevelled, malodorous, quiet, contradictory, incongruent and at times perplexed. She reported that she believed people were trying to kill her and she was diagnosed with a psychotic illness, including schizophrenia. The opinion of multiple clinicians was that psychosis was a major part of her clinical picture.”
She was placed under compulsory treatment, as she had “a clear intention to suicide”.
The assessing doctor regarded her as “psychotic, at high risk of going ‘absent without leave’ from the unit and at high risk of suicide if she was not hospitalised”.
She was discharged in September and lived in a flat, where mental health workers continued to visit her.
On 17 December 2021, she was reviewed by her community psychiatrist, who found she was not suicidal, but noted her disorganisation and medication non-compliance put her at risk unless she was “closely managed”.
The next day, she tried to kill herself – but was saved by her landlady and re-readmitted to hospital.
During that admission, she told clinicians the suicide attempt was not planned and she was “happy to be alive” and looking forward to spending Christmas with her family.
The psychiatrist’s clinical notes at the time said it appeared Gabriella had ADHD, not schizophrenia, and they planned to reduce some medications and restarted her on Ritalin.
He later told the coroner he was of the opinion that Gabriella suffered from ADHD, in addition to depression and a personality disorder – mainly impulsivity and unpredictability.
There was a Zoom meeting with her father, who had been unaware she was back in hospital.
“Robert recalls asking why Gabriella was back in the mental health ward and being told it was because her ‘medications were wrong’, but that she was ‘all right now’.”
According to the medical notes from the meeting, the psychiatrist explained Gabriella had been readmitted because she was depressed and having thoughts of harming herself.
The notes show the father asked what clinical support she needed and was advised that Gabriella needed support and medication, i.e. Ritalin.
He arrived in Palmerston North on 23 December to pick her up, and had a meeting with staff and given some paperwork about medication.
He told the coroner he was not aware that Gabriella had been admitted to hospital because she had tried to kill herself, and that he did not know that she was a danger to herself.
“He recalls that one of the doctors may have said something about suicide or suicidal tendencies, but he was not sure.”
When they stopped at her flat to pack for the trip, one of the flatmates whispered to Robert Freeland that Gabriella had some specific items in her bag and he needed to “get them out”.
However, when he asked his daughter if she had anything potentially harmful in her luggage, she denied it.
Home in Auckland the following day, they had a great time as planned, he said.
They went shopping, bought groceries and had lunch together. Gabriella went for a walk and visited her aunt.
That afternoon, she spoke briefly to her brother Jared, and they “had a little laugh” before she went into her room.
That is where she was found dead a couple of hours later.
‘Tragic outcome’ continues to affect clinical team
MidCentral District Health Board held an independent review into the death, which found “Kate” had a tendency to downplay her risk and this was not taken into account in planning.
“During interviews some staff expressed disquiet about the leave process and were not confident that Robert knew about the suicide attempt.”
The reviewers said two indicators should have prompted staff to reassess Kate’s risk: the change in her diagnosis; and her risk history and the serious attempt to kill herself only two days before.
They made several recommendations, including improvements to assessment, treatment, leave and discharge planning and documentation.
In its response to the coroner, Health NZ provided details of those new procedures, including the information that should be provided when a patient goes on leave and planning.
The psychiatrist who was treating Gabriella on the ward told the coroner that the decision to give her leave for Christmas was made by the multidisciplinary team after “an intense five days of assessment, treatment and observation”.
“It was in response to strong patient and father requests and was sanctioned when Gabriella appeared to be improving and future focused.”
Plans and support measures were in place.
“Despite that, and the team doing their best, a tragic outcome no-one wanted followed. The whole team and I remain affected by the tragic outcome in this case and our sincere condolences remain with Gabriella’s family.”
Experienced psychiatrist Associate Professor Ben Beaglehole, who provided expert advice to the coroner, noted the diagnosis of schizophrenia was the best explanation for the mental problems that emerged for Gabriella from 2017.
He said the change in diagnosis to ADHD over two days raised a number of questions, including whether it reduced vigilance to abnormal mental state, and influenced the decision to grant leave.
The timeframe for moving from a serious suicide attempt on 18 December 2021 to extended overnight leave on 23 December 2021 was “relatively short if the driver of Gabriella’s risk behaviours is thought to be partially treated psychotic symptoms”.
Ritalin did not help with psychotic symptoms, and could sometimes make them worse, although there was no evidence of this in Gabrielle’s case.
He noted however, that acute inpatient services often ran near full capacity with high-risk patients, and care must be taken “when applying the benefits of hindsight to evaluating outcomes from complex clinical scenarios”.
Coroner’s recommendations
Coroner Anderson said she was mindful of “the dangers of hindsight bias” and accepted it was not possible to conclude that Gabriella would still be alive if she had not been granted leave, or if her father had received better information.
However, she said the decision to grant Gabriella leave so soon after a serious suicide attempt, and a significant change in clinical diagnosis, was unwise.
“There was no opportunity to properly consider the impact of the changed diagnosis or the recent alteration in medication before Gabriella left the unit with her father.”
Furthermore, while there was uncertainty about exactly what Robert Freeland was told, it was clear he was not aware of the specific details of the suicide attempt days previously, nor the risks of taking her home.
The coroner acknowledged the changes MidCentral had made to policies and procedures, but has further recommended that Health NZ:
- Commission an independent review of culture at the in-patient unit, including staff communication
- Review the resourcing of the unit to ensure that it is appropriately and safely staffed
- Continue regular audits about compliance with the new policies and procedures, particularly those relating to Leave, Family-Whānau Meetings, and Multi-Disciplinary Team Meeting decision-making.
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– Published by EveningReport.nz and AsiaPacificReport.nz, see: MIL OSI in partnership with Radio New Zealand
