The death of a woman experiencing postnatal depression could have been prevented and reflects a system where mental health inpatient treatment is in short supply, a coroner has found.
Queensland Deputy State Coroner Jane Bentley on Friday delivered her non-inquest findings into the death of a woman referred to as 'Mrs S' in June 2021.
Mrs S suffered unsurvivable brain injuries due to actions she took with the intent to end her own life in her home south of Brisbane.
Her husband was out buying lawnmower fuel at the time and her eight-week-old baby was asleep in their bedroom.
Mrs S died in hospital five days later and her organs were donated.
For the three days prior to her death, Mrs S was an inpatient at the Logan Hospital Mental Health Unit but not at a specialist care centre such as the Lavender Mother and Baby Unit at Gold Coast University Hospital.
Ms Bentley said the death of Mrs S may have been prevented if an appropriate mother-baby inpatient admission had been available to her.
"The current number of such facilities in Queensland remains about 10 times below the recommended ratio," Ms Bentley stated.
Mrs S had experienced post-natal depression and since December 2020 had received mental health support from Metro South Addiction and Mental Health Services after also experiencing anxiety during pregnancy about the pending birth and motherhood.
She was referred to Metro South's Perinatal Wellbeing Service but Mrs S did not respond to attempts to contact her about the referral.
Mrs S presented to the Logan Hospital emergency department on referral from her GP 10 days prior to her death with anxiety, insomnia and suicidal ideation.
"She was experiencing poor sleep and her baby was difficult to settle," Ms Bentley stated.
"It was noted that these factors had increased her anxiety and worsening mood over the past weeks and she had experienced a panic attack the night prior."
The Queensland Maternal and Perinatal Quality Council in March 2022 reviewed the circumstances around the death and found Mrs S and her family made every effort to seek appropriate care given their resources.
"Every effort to provide appropriate medical care was made, given the resources available to treating clinicians and teams," the council found.
The council also found a lack of public mother and baby beds to treat women with severe postnatal depression contributed to her death.
"Had there been a mother and baby bed available ... Ms S would have likely received appropriate care and her death would most likely have been prevented," the council stated.
The council noted that there were only four public mother-baby beds for Queensland's 1000 mothers presenting to emergency services in a "suicidal crisis" per year.
Queensland's ratio of specialist beds compared to births is more than six times worse than in Victoria, a state that also has too few beds.
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