Health system failed victim


TWEED coroner Jeff Linden has slammed the NSW Health service blaming the suicide death of a Tweed woman on a penny-pinching health service.

Mr Linden said on Tuesday he was satisfied that the death of 67-year-old Charlotte Trunshnig was preventable.

Ms Trunshnig died on February 4, 2006, after she drank bleach, doused herself with methylated spirits and set herself alight.

She was barely alive when the police arrived at her home in Tweed Heads and was heard repeatedly saying, "Let me die". Charlotte Trunshnig died at 12.25pm that day, about 20 hours after being released from the Tweed Hospital.

Despite multiple suicide attempts, self mutilation , admissions to the Tweed Hospital during late 2005 and medical reports of Ms Trunshnig as a high suicide risk, she was never admitted to the mental health unit nor provided with care she requested.

"It is probably the most tragic example of NSW health's inability and/or failure to deal with individual cases in an appropriate manner," Mr Linden said.

He concluded that realistic health goals "are dictated by and subject to economic outcomes".

Mr Linden said Ms Trunshnig's death epitomised a culture that had unfortunately evolved where sound (and in this case simple) medical decisions could not be made because they required or were seen to require approval from economic managers.

"In this particular case the deceased merely required full-time 24-hour care for a period of time," he said.

The hospital, due to policy or a lack of policy was unable to provide that care even in a transitional way.

Mr Linden, an outspoken campaigner for more mental health services for the North Coast, delivered his findings after days of evidence from health workers and friends of the deceased.

"I am satisfied that this death highlights a litany of systems failures within the NSW Health service and the approach to suicide," Mr Linden said.

"It appears that staff cannot approve anything outside 'normal' parameters without resort to management and the perception of inevitable rejection or failure of management to deal professionally and promptly with those requests leads to a culture of "why bother asking".

A lack of communication between departments and a philosophy of mental health services to treat and remove patients from hospital as soon as possible along with subjecting unqualified staff to decision making beyond their level of expertise, contributed to Ms Trunshnig's death.

"This problem has been evident in Tweed Heads and Lismore for two years and is partially due to a lack of available mental health beds within the region and enormous pressure on staff to make beds available to those assessed as most needy," Mr Linden said.

As a result of the inquest Mr Linden recommended to state health authorities that suicide threats and attempts be accepted as prima facie evidence of mental illness with the health service given the power to detain the patient for up to 28 days on an involuntary basis with a review by a magistrate or mental health tribunal if more time was needed.

He also recommended that a fully qualified psychiatrist or other fully qualified professional be nominated as the primary care giver for any patient identified as the above and all or any ancillary care be subject to that health worker's direction.

As well Mr Linden recommended ancillary care be co-ordinated and that social welfare services have the ability to provide, at its discretion, 24 hour, seven day, at home care for as long as appropriate in the event that full time admission to the relevant hospital for any reason is not feasible.

NORTH Coast Area Health Service (NCAHS) director for mental health Richard Buss responded to Mr Linden's findings yesterday saying that in 2006 NCAHS undertook an investigation, which included an independent clinical review of the patient's care and treatment.

He said the review found there were no major contributing factors that would have altered the outcome for this patient.

"The investigation confirmed that the patient was seen by appropriate clinical staff who adhered to Mental Health legislation and applicable NSW Department of Health policies," he said.

"The findings in the Coroner's Report are being assessed and will be thoroughly reviewed in light of the independent clinical review and any discrepancies will be investigated." Mental Health Services in the North Coast have recently been enhanced by the introduction of the Specialist Mental Health Service for Older People program. This service provides multi-disciplinary mental health assessment, consultation, care planning and collaboration to older people with complex conditions and/or mental illness. The service can be delivered in collaboration and consultation with key service partners as required.

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