South West mum pushing for coronial inquest into daughter's death

In the two weeks leading up to Tahlia Stoveld’s death in May last year, her mother and grandmother were desperately trying to reach out to mental health professionals to find her help.

Tahlia, who had experienced mental health issues in the past, was displaying signs that deeply concerned her family members.

Despite their constant attempts to source Tahlia help and reduce the risks associated with her mental health vulnerabilities her mum Lisa Chatwin said help was not made available or was inadequate.

“Tahlia was clearly disorganised, disorientated and was displaying disassociated behaviours and actions, yet no mental health clinicians identified her vulnerabilities, the red flags of depression or the obvious abnormal behaviours.”

Ms Chatwin is now pushing for a coronial inquest to look into the “systematic failings” and circumstances which led to Tahlia’s death hoping it will lead to change in a system that failed to help her daughter.

“It is about highlighting how inadequate the system is. What is accepted as norm is not acceptable, and the way people are treated in the system and family members is so humiliating,” she said.

“It is not acceptable for me to be grieving the loss of my daughter knowing this was a situation which was beyond my control and could have been resolved with a positive outcome.

“Tahlia needed help and she did not get it, as a family we needed help and we did not get it. She was may daughter and she was loved, she was a really valued member of our family.

“There was a two week timeframe when her mental health was unravelling and we tried to intervene.”

During those two weeks her family were told by Tahlia’s partner that her medication had changed. Tahlia wanted her family to care for her son because she was not coping and went missing.

Tahlia contacted her mother distressed and confused. Her mum arranged for her grandmother to pick Tahlia and her son up and made the frantic dash to Perth to be with them.

The next day she was missing. Her family, along with her partner, had both reported Tahlia as a missing person to police.

Tahlia was located in the early morning the following day, a friend contacted the family to tell them Tahlia had been taken to an emergency department.

For the next day Tahlia was left on a trolley in the hallways of a hospital while she waited for a bed to become available at Graylands Hospital.

Ms Chatwin said the families pleas to hospital staff to admit Tahlia as an involuntary patient were not met, they were told it was likely a psychiatrist would assess her as competent.

Throughout those two weeks calls were made to clinicians to have Tahlia assessed and attempts were made with police to list her as a missing person around the time she died.

“Tahlia had been confused and her thoughts were clearly disorganised earlier in the day and she was displaying anti-social, unstable behaviour,” Ms Chatwin said.

“Tahlia was not interested in engaging with her son and did not want to see him, which was an indicator of disassociative behaviour.

“Her mental health had been breaking down over several weeks and was escalating, yet nobody appeared concerned or had the skills to identify Tahlia’s mental health vulnerabilities or identify the depression and potential suicide red flags.”

On the day Ms Chatwin found out her daughter had passed, she had to persuade police to list her daughter as a missing person. About three hours later she received the devastating phone call to inform her that Tahlia had died the night before.

Mental health and suicide prevention advocate

Alison Xamon MLC is a mental health and suicide prevention advocate who has worked as the president of the WA Association for Mental Health, vice-chair of Community Mental Health Australia, and sat on the board of Mental Health Australia.

She said there was no question that Ms Chatwin was failed by the system and had unfortunately heard from many families that their concerns were not taken seriously.

While there were people who navigated their way through the mental health sector with success, Ms Xamon said the effects of failure could be catastrophic, as was the case with Tahlia.

“What we have here is a woman who was clearly in distress with a number of different people around her that had information which needed to be taken into account,” she said.

“One of the key distresses for Ms Chatwin was trying to get people to hear that Tahlia’s behaviour was completely out of character and have her knowledge respected as someone who obviously knew Tahlia her whole life.

“For whatever reason that was not given the weight it should have received.” 

Ms Xamon said the new Mental Health Act put a heavy emphasis on the need to take into account what is being said by someone’s carers and family members.

“It is absolutely critical when clinicians make an assessment of somebody who maybe at risk of suicide, or self harm, or harm of others, to take into account a hefty degree of weight what is being said to them by people who are close to that person.”

Ms Xamon said it could be difficult for health professionals to identify a next of kin or to identify who they should be speaking to, and part of that was if they were dealing with a person who had impaired judgement or psychosis they themselves may not be well.

“What happened to Tahlia is not unusual, it is common for people who are in crisis to move from service to service and from clinician to clinician without ever forming therapeutic relationships.”

Ms Xamon said she was deeply concerned by the issues experienced by Ms Chatwin, which were the same issues which initiated the Stokes review in 2012 and subsequent Coroner’s report about early discharge for people who had subsequently suicided.

Ms Xamon wrote to the WA’s chief psychiatrist who has a serious concern about wanting to address the issues that arose from those reports.

“He said we are so far down the track in terms of trying to improve the system but we are still seeing really basic failures,” she said.

“Some of the basic failures include inconsistent communication with carers and family members and failure to take into account the advice that was being received.”

Ms Xamon said the system was doing well when people were settled in the system and appropriately referred to non-government organisations for ongoing support.

She said where the system needed improvement was when people were in acute services, or in a crisis who turned up to emergency departments.

“It is distinctly better than it was eight years ago but that is only one part of it. At the acute end we are still looking at a system that is in crisis or has periods of crisis.”

The one thing Ms Xamon is calling on is to make sure there were no cuts to mental health or suicide prevention services because the effects could be devastating.

“Anything that will set us the smallest part backwards is the wrong way. We have a 10 year services plan and we need to stay on track and investing in it.”

Mental Health Commission

A spokesperson from the Mental Health Commission said the Mental Health Act 2014 provided for the recognition of carers and families in the treatment, care and support of people who have a mental illness.

The spokesperson said when someone is making a decision about a person’s best interests under the Act, the person or body making the decision must have regard to the person’s wishes, as well as a close family member or a parent/guardian in the case of a child.

“The Commission expects service providers to provide appropriate and safe treatment and care for their patients (both adult and children), acknowledging that it is up to the service provider to prioritise resources in accordance with clinical needs and to manage the specific arrangements around how that can occur.

“Suicide prevention cannot be seen in isolation of the broader mental health system and the social and health circumstances of communities.”

The Mental Health Commission is providing greater support to communities to help reduce suicide risk.

The spokesperson said this included 10 new regional Suicide Prevention Coordinators to identify and address local suicide related issues through prevention activities in each region.

“We are also working, together with other stakeholders, to achieve the actions outlined in the WA Mental Health, Alcohol and Other Drug Services Plan 2015-2025,” the spokesperson said. 

“These will include developing and implementing a new prevention plan and suicide prevention strategy; greater consumer, carer, family and community engagement across the sector; as well as greater investment in prevention and promotion services and community-based services.”

For support, call beyondblue on 1300 224 636 for 24/7 free counselling, Rurallink on 1800 552 002, or Lifeline in a crisis situation on 13 11 14.