A young Perth woman may not have taken her own life if she had been treated differently by the state’s mental health services, Western Australia’s former chief psychiatrist has told a coronial inquest.
Five patients from Alma Street Clinic died between 2011 and 2012, prompting a review led by then-chief psychiatrist Rowan Davidson.
His report found clinical errors, like discharging a patient prematurely, could affect the quality of care however, family members complained that the review left many questions unanswered and poor practices unchanged.
The State Coroner is now revisiting the deaths.
Twenty-year-old Carly Jean Elliott was found dead in her room in March 2011, after a battle with mental illness.
In September 2010, she was taken to Fremantle Hospital Emergency Department after saying she wanted to kill herself, however left without being seen by a psychiatrist.
One month before she took her life, she was assessed by Alma Street Clinic’s Community Emergency Response Team, who concluded she was not at risk.
Dr Davidson told the inquest while he was uncertain whether the woman’s death was preventable, he believed actions could have been taken to reduce the likelihood of her suicide.
He said he believed mental health services could have focused more on creating a working relationship with Ms Elliott.
Dr Davidson noted Ms Elliott had been “difficult to engage” with mental health workers, although said staff within the sector should be more persistent when trying to treat some patients.
He suggested workers communicate more with family members or carers when permission was granted.
“And that is given a priority where it is quite clear families are exhausted and have high levels of emotional turmoil,” Dr Davidson told the inquest.
He said areas of the mental health service needed to be better integrated at the time of Ms Elliott’s death, although noted the sector was currently addressing that problem.
Now in its third week, the inquest has so far heard from family members and medical staff linked to the deaths.
It is expected to hear from the current chief psychiatrist tomorrow, while the acting director-general of health, Professor Bryant Stokes, is due to appear on Thursday.
He completed an independent review of the mental health system in 2012, recommending strategies to prevent similar deaths.
He will be questioned on whether those strategies have been successfully implemented.
The families of those who died say they hope the inquest will finally provide answers to some long ignored questions.