Coroner delivers damning finding on South Australian mental health care

19 July 2018
Lawyers for the mother of a young woman who died after attempting suicide when she was told she was to be discharged from hospital care believe the coronial inquest into her death has revealed deep flaws in South Australia’s mental health system.

Maurice Blackburn’s Head of Medical Negligence, Dimitra Dubrow said the State Coroner, Mr Mark Johns today delivered a damning finding about the mental health care that 24 year old Chrystal Ross received.

“Chrystal was let down by the system that was meant to protect her,” Ms Dubrow said.

“She was seeking help in hospital for her acute anxiety and depression when she was informed that there wasn’t a hospital bed available for her in the system and that she would be discharged.

“The tragedy here is that there was a missed opportunity for Chrystal to be transferred to an available bed at Glenside Rural and Remote Unit. Incredibly, this scarce resource was turned down shortly before her death,” Ms Dubrow said.

“It was this news that she would be discharged, delivered by the community mental health team nurse and without her GP’s knowledge, that the Coroner found distressed her and most likely led to her suicide attempt.”

Ms Dubrow said the Coroner also made a strong finding about the mental health system in South Australia and the concerning lack of mental health beds which led to the type of poor decision-making that occurred in this tragic case.

“The irony in this case is that a bed finally became available at the Glenside Rural and Remote Unit only for it to be turned down when Chrystal needed it most.” 

“There were a series of miscommunications which just kept escalating about whether the bed was still required which just shouldn’t happen when the safety of a vulnerable patient such as Chrystal is involved,” Ms Dubrow said.

“I heartily welcome the Coroner’s recommendation that there needs to be a dramatic increase in the number of mental health beds available in South Australia to reduce the likelihood of this type of systemic dysfunction continuing into the future.”

“It is clear from this inquest that the role of the Community Mental Health Team is unclear when it comes to hospital patients and that there needs to clear lines of responsibility and decision-making when it comes to psychiatric decisions about patient care, particularly around hospital discharge,” Ms Dubrow said.

“We welcome the changes already made by Country Health SA in response to Chrystal’s tragic death and that the service has acknowledged that the expected care was not provided in Chrystal’s case and apologised to Chrystal’s family for this.

“Importantly, it is now clear that a person who is on a waiting list for a mental health bed will not be removed from that list without being reviewed by the psychiatrist who requested the bed in the first place - this is a much needed protective measure,” Ms Dubrow said.

Ms Dubrow said while it is critical that appropriate guidelines and policies are in place, this coronial finding makes clear that structural changes around very clear decision-making guidelines are required to prevent such tragic outcomes because of human error.

Chrystal’s mother, Michelle van Dyk also spoke following the delivery of the inquest finding.

“Chrystal was my beautiful daughter and there’s not a day that goes by that I and our family and friends don’t feel her loss deeply,” Ms van Dyk said. 

“I’d like to thank the Coroner for taking the time to make such a thorough analysis and for his recommendations.

“There is a lot of information to absorb, but if the Coroner’s findings and recommendations prevent other deaths like Chrystal’s, then her death will not be in vain,” Ms van Dyk said.

“I welcome the Coroner calling for more mental health beds in South Australia.  Had there been a bed available, Chrystal would have been transferred earlier and I would still have my daughter now.

Practice Areas: