The ACT Coroner has urged mental-health authorities and the Australian National University (ANU) to cooperate more closely after a young student killed himself while living on campus in 2018.
Joshua* took his life in his room at a residential hall between late July and mid-August 2018. He was 18 years old.
Coroner Ken Archer's report on the death found Joshua had been depressed and was estranged from his family.
He had kept to himself at university and was isolated from other students.
However, Mr Archer said there had been a warning of suicide risk just weeks before Joshua's death, when an ambulance was called to his ANU residence after he harmed himself.
He was taken to Canberra Hospital and talked to mental-health staff, but made it clear he did not want any information shared with his family.
His case was closed before his death several weeks later.
Mr Archer noted that ACT Mental Health Services (ACTMHS) would not provide Joshua's parents with access to information about him, including that they had closed his case.
"Joshua's parents are haunted by the feeling that, if they had known that he was effectively without professional engagement or support, they could have done more to intervene," the coroner said.
"Given his refusal to engage with his parents, there was little they could do to help their son.
"They could have done no more than they did."
A family friend, Nathan*, contacted Joshua and tried to follow up with ACTMHS to ensure the student was attending his medical appointments after his hospitalisation.
"Nathan's support for Joshua was a selfless expression of his concern. He has felt Joshua's loss deeply," Mr Archer said.
The coroner said Nathan had done all he could to alleviate Joshua's distress.
Lack of information sharing questioned
Mr Archer stopped short of blaming the university or ACTMHS, but noted a shortfall in coordination between them.
He recommended both agencies rethink their policies, and set practical rather than inspirational goals, including on the transfer of care.
"The issue wasn't so much whether the file closure was indicated as whether appropriate 'wrap-around' care was in place through the ANU," the coroner said.
Mr Archer said the evidence suggested the ANU's response to Joshua's mental illness was not well-coordinated. He called for a review of the university's mental-health strategy.
However, his most significant recommendation concerned information sharing and ACT government advice to health workers about how much of a patient's personal information they could disclose.
Mr Archer suggested the government examine this information disclosure in any future review of the Mental Health Act.
In a statement to the ABC, the university said it was on track to implementing all the coroner's recommendations this year.
"Nothing is more important than our students' welfare and this was a tragic loss," the ANU said.
"Our thoughts continue to be with Joshua's family.
"We continue to collaborate with ACT Health and other providers to the maximum extent permitted by privacy legislation."
* The coroner did not use these people's real names and did not name the student's residential hall.
