The suicide of a 16-year-old boy could potentially have been avoided if more mental health services were available in Tasmania, a coroner has found.
WARNING: This story contains details that readers may find distressing.
The teenager's body was found at Bonnet Hill, in Hobart's southern suburbs in March 2017, two days after he was discharged from a private mental health clinic in Melbourne.
Coroner Kenneth Stanton found the mental health of the boy, whose name is suppressed for legal reasons, had deteriorated in late 2016, and he began receiving treatment for depression in October.
After telling his doctor that he regularly had suicidal thoughts, he was admitted as an inpatient at two Victorian facilities, spending almost three weeks at the Albert Road Clinic (ARC) in February 2017.
He was discharged from the ARC on March 4, with a plan for him to return to the facility a few weeks later to receive further treatment.
But two days after his discharge, and one day before he was set to return to school, the teenager took his own life.
Mr Stanton said the boy's death was the "source of deep sadness and intense grief for his family and friends", noting that his mother had later taken her own life after his death "as a result of the understandable pain she experienced".
The coroner found that ARC psychiatrist Christine Simons should have given the boy's parents more information about the increased risk of suicide in the first days after discharge from an inpatient facility, as well as informing them that he had discussed how and where he might take his own life.
"Had [the boy's] parents been aware of those specific matters, they may have been able to take additional steps to prevent him from going to the place where he took his life, particularly during the high-risk period shortly after discharge," Mr Stanton said.
Dr Simons provided evidence to the inquest that the boy was in a safe, stable state and she was certain he could be safely discharged.
She also said she interpreted the discussion about suicide methods as distress signalling, and not necessarily statements of genuine intent.
Tasmanian inpatient options 'less than ideal'
The coroner said the teenager's mother wanted him to be treated in an inpatient facility, and a lack of suitable facilities for adolescents in Tasmania meant he was admitted to the ARC.
He found the boy had "experienced the disadvantages of inpatient treatment interstate" despite the best efforts of his parents to support him.
"It would have been preferable for [the boy] to have been treated close to home."
The coroner found that the boy would have had to be admitted to the Royal Hobart Hospital in order to receive inpatient treatment in Tasmania, which would have seen him hospitalised in a paediatric ward that did not specialise in adolescent mental health, or in an adult psychiatric ward.
"It is uniformly accepted that neither of these options are appropriate," Mr Stanton said.
"All of the professional medical experts who gave evidence on the inquest agreed that treating young people in hospital wards that are not specifically designed for adolescent psychiatric care is less than ideal."
State still waiting on new mental health facilities
In 2015, coroner Olivia McTaggart made sweeping recommendations about improving youth mental health services, after the suicides of six teenagers.
Those recommendations had not been implemented by the time of the boy's death, but Premier Peter Guwein has announced plans to create adolescent mental health wards at both the Royal Hobart Hospital and Launceston General Hospital.
Mental Health Minister Jeremy Rockliff says beds are now available at both hospitals for adolescent mental health patients.
Chief psychiatrist Aaron Groves told the inquest that there were proposals to create community adolescent inpatient facilities in the state, rather than in hospitals, but Mr Stanton found that many of those would "still take years to be implemented".
"On the evidence before me I cannot exclude the possibility that the availability of and referral to community-based services in the days following [the boy's] discharge from the Albert Road Clinic might have led to a different outcome," he said.
Mr Gutwein said the government was implementing the recommendations of a 2020 review into child and adolescent mental health services and would consider the coroner's recommendations.
