Joshua Klumper was desperate for help the night he asked his grandmother to take him to hospital.
The 17-year-old, who was diagnosed with autism, had a history of mental health issues and multiple suicide attempts.
Joshua's grandmother took him to the emergency ward at Gold Coast University Hospital on September 2, 2017.
His mother, Ursula Wharton, said he waited for four hours before staff told him they couldn't help him that night.
"There wasn't anything happening, there was frustration and so Josh left," she said.
Joshua attempted to take his life three days later and eventually died in intensive care on September 16.
With a coronial inquest into his death underway, Ms Wharton is calling for mandatory training for staff treating patients with autism.
Ongoing research indicates "overwhelmingly negative" health outcomes for people such as Joshua.
Compassion in care
Ms Wharton told the inquest that the treatment of her son lacked compassion.
"I've been advocating from the very beginning that compassion is medicine," Ms Wharton said.
"Mental-health nurses generally get into the job because they're compassionate people and want to help people."
Ms Wharton said the way hospital staff interacted with people experiencing a mental health crisis should be reviewed.
"I think a lot of policies and procedures don't reward the time spent in showing compassion," she said.
"The mental-health nurses [who] saw him on the last night — 30 years in the job, but with very limited understanding, experience, training in ASD.
"There are no policies around how to see a person with ASD through an ASD lens, which is essential for understanding who they are and what's going on for them."
Multiple attempts for help
One year earlier, Joshua had suffered a "depression attack" which involved "a sudden, overwhelming desire to take one's life".
"They [medical staff] didn't see a need to elevate — you know, hurry," Ms Wharton said.
About an hour later, police returned Joshua to hospital after an attempt to take his own life.
"But unfortunately, the child and youth mental health [unit] had released him within a couple of weeks," Ms Wharton said.
She said the family struggled without support over the next 12 months.
A spokesperson for Gold Coast Health said "due to the ongoing coronial inquest, we cannot comment on the particulars of this case".
"We understand how difficult it is for loved ones of patients who suicide after leaving the hospital setting, and the impact of such tragedies is felt across the health service, particularly by frontline staff," the spokesperson said.
"Caring for patients with autism spectrum disorders (ASD) is inherently complex. The disorder sits on a spectrum and every person with autism is unique.
"An autism diagnosis is not a mental health diagnosis, but rather, it's a neurodivergence.
"Staff treat and care for patients with a vast array of behavioural, communicative and social traits every day."
The nuance of language
Pia Bradshaw is completing a PhD at the University of Queensland's Faulty of Medicine, focusing on the experiences of autistic adults in the healthcare system.
"My preliminary findings suggest that the overall experiences and outcomes of autistic adults, supporters and GPs are overwhelmingly negative," she said.
Ms Bradshaw, who is autistic, said "antiquated and pathologising knowledge, lack of education and training" created barriers.
"Autistic people, both diagnosed and undiagnosed are being overlooked, gaslit, misdiagnosed and mis-medicated," she said.
"Consequently, autistic people are disengaging from and avoiding seeking care for physical and mental health concerns because of previous negative interactions.
"This shows a great need for the broader medical collegiate and its professional staff to learn from the direct first-hand experiential experiences of actually autistic people."
Ms Bradshaw said "the power of language can have profound and adverse effects on autistic people and culture".
Views that consider neurodivergence as "abnormal, unhealthy, ill, diseased and disordered" can "discredit people as mentally ill, diseased and disordered," she said.
"In my opinion, we need to move away from 'with autism' because it objectifies and dehumanises the understanding that we are living, breathing, whole autistic people."
Ms Bradshaw said people "cannot see someone's autism" and that it can be "dependent upon environmental sensory stimuli and how well an autistic person is supported, accepted and accommodated across all key areas of their lives".
"Humanising language can radically transform individual and collective attitudes from a state of fear, suffering and hatred, to one of love, joy, and acceptance," she said.
The Brisbane Coroners Court has adjourned the inquest into Joshua Klumper's death until later this month.
