A coroner is examining the deaths of Barry Ellery, 77, Miranda Meyer, 37, and Kendal Quicke, 31, at The Prince Charles Hospital between May and December 2023.
A treating psychiatrist of one of the patients told the inquest while improvements had been made, the mental health unit still had “a major problem with bed capacity”.
The coroner will consider whether any additional changes to the delivery of mental health services within the Metro North Hospital and Health Service should be made.
A coroner is examining the appropriateness and adequacy of the mental health care and treatment provided at the time of the deaths. (ABC News: Michael Lloyd)
A coronial inquest into a cluster of three patient suicides within a seven-month period at the mental health unit of a major Brisbane hospital has heard that the unit remains “overcapacity all the time”.
Warning: This article contains references to mental health and suicide.
Coroner Megan Fairweather is investigating the deaths of Barry Ellery, 77, Miranda Meyer, 37, and Kendal Quicke, 31, which occurred at The Prince Charles Hospital between May and December 2023.
She is examining the appropriateness and adequacy of the mental health care and treatment provided by the Metro North Hospital and Health Service at the time of these deaths.
A treating psychiatrist for one of the patients, whose identity is protected by a non-publication order, informed the hearing in Brisbane that during the period in question, patients from the mental health unit were frequently admitted to the thoracic ward.
The mental health unit consists of two wings with a total of 60 beds. However, the psychiatrist stated that it was common for up to 12 mental health patients to be admitted to the thoracic ward concurrently in 2023.
She added that while improvements have been implemented since the cluster of suicides, and the thoracic ward is no longer used for psychiatric patients, the mental health unit continues to face “a major problem with bed capacity”.
“We can’t meet the need in our catchment area,” the psychiatrist said.
The mental health unit at the Prince Charles Hospital has two wings with 60 beds. (Facebook: The Prince Charles Hospital)
On the opening day of the inquest, Ms Fairweather heard details regarding the care provided to Ms Quicke, who died on November 12, 2023.
A trainee psychiatrist involved in her care, also subject to a non-publication order, testified that at the time of the suicides, his inpatient workload comprised approximately 11 to 13 patients, whereas the recommended number is around four to five.
His consultant psychiatrist informed the inquest that the trainee’s workload had decreased since Ms Quicke’s death.
The consultant psychiatrist stated that she reviewed Ms Quicke on November 2, following her admission with major depressive disorder and “a range of trauma-related symptoms which appeared to be chronic in nature”.
Ms Quicke also had diagnoses of attention deficit hyperactivity disorder, autism spectrum disorder, and borderline personality disorder.
However, the psychiatrist noted that Ms Quicke “presented as someone who was motivated to follow advice and engage in a plan to improve her mental health”.
“I felt Kendal had a very positive prognosis,” the psychiatrist commented.
“I felt she was going to do very well. I felt hourly visual observations are appropriate.”
Two women and one man took their own lives between May and December 2023 at the Prince Charles Hospital in 2023. (ABC News: Michael Lloyd)
The inquest heard that nursing staff changed Ms Quicke’s observation schedule to 15-minute visual checks on November 5. However, neither the treating psychiatrist nor her trainee recalled being informed of this change before the suicide.
On November 7, following a review at a multi-disciplinary team meeting involving doctors, nurses, and allied health staff, Ms Quicke was deemed well enough for general observations, which involve checks every four hours.
She died by suicide five days later.
The inquest follows an external health service investigation triggered by the deaths. This investigation found that the mental health wards at The Prince Charles Hospital were “no longer fit for purpose” and posed safety risks that required “urgent” attention.
Deaths by suicide within mental health units are classified as nationally reportable sentinel events, defined as “adverse patient safety events that are wholly preventable”.
The review, released in 2024, concluded that the two wards did not align with “contemporary guidelines for mental health facilities”.
“[The facilities] are not conducive to mental health recovery and wellbeing for consumers, and they pose a number of potential safety risks for both consumers and staff,” the review stated.
Ms Fairweather informed the court that her role as coroner is a “fact-finding exercise”.
“It’s not my role to cast blame.”
She will consider whether any further changes to the delivery of mental health services within the Metro North Hospital and Health Service are warranted.