The death by suicide of an 18-year-old man in student accommodation has highlighted a lack of co-ordinated mental health care at the Australian National University, a coronial inquest has found.
It has also recommended the university publicly publish a review into its mental health strategy.
The teenager, referred to only as Joshua in the findings, was found dead in his room in an unnamed residential hall owned by the university on August 16, 2018.
Coroner Ken Archer said the man died between July 31 and August 16 that year.
Mr Archer said the case "highlights a shortfall in co-ordination" between ACT Mental Health Services and the university.
Joshua moved to Canberra from interstate and started at the university in February 2017.
He had exhibited depressive traits from his teenage years but had no formal diagnosis of mental illness.
When Joshua was 14, he witnessed the aftermath of a serious car crash involving his mother. His mother believes this caused the start of his mental health decline.
While at university, Joshua lived a solitary life. People who did have contact with him thought he was depressed.
By May 2018, Joshua's "isolation became even more pronounced", Mr Archer stated.
He consumed alcohol, self-harmed and refused to speak to his family. He also refused financial support.
Joshua was taken to Canberra Hospital on May 27, 2018, after a suicide attempt.
While he accepted treatment, he didn't want to be admitted to the mental health ward and didn't meet conditions for a compulsory order.
At his parents' request, a friend of the family attended the hospital and continued to check on him.
The hospital put Joshua in contact with a crisis assessment and treatment team, and referred him to a psychologist.
The coroner found the university did not respond to Joshua's mental health challenges in a co-ordinated way.
Mr Archer found it was not clear how the university's mental health strategy "was given practical application" in Joshua's case.
He said there was a lack of evidence that there was a co-ordinated attempt to identify Joshua's psychological stressors and to ensure supports were in place.
"Given the seriousness of the act of self-harm this absence of documentation and a care plan is surprising," he said.
The residential hall did engage with Joshua both before and after his suicide attempt. Employees would visit his room and held regular meetings with him.
However, Mr Archer said the extent to which Joshua was encouraged to access mental health support was less clear.
Mr Archer has recommended the university publicly publish its review into the mental health strategy in October, 2023. He also urged residential hall operators to co-operate in the review.
He recommended the university and ACT Mental Health Services revisit a memorandum of understanding concerning students with mental health challenges, informed by the coronial inquest.
Mr Archer did acknowledge the university had developed a student safety and wellbeing plan, but he said the court was not given evidence of practicalities of the relationship between clinical services and residential halls.
He said the plan was "directed primarily at issues surrounding sexual assault rather than being a detailed response to mental health issues in the student population".
In a response to preliminary findings the university said "under present day case management process ... a greater level of wrap around support could have been afforded".
- Support is available for those who may be distressed. Phone Lifeline 13 11 14; Mensline 1300 789 978; Kids Helpline 1800 551 800; beyondblue 1300 224 636; 1800-RESPECT 1800 737 732.
