“She was a vulnerable girl and she wasn’t protected.”Confused and angry, Malcolm McKenzie and his wife Dorothy McKenzie still can’t quite grasp the events leading up to the death of their daughter Deborah in March of 2013. Deborah had been released from hospital after a suicide attempt, just 24 hours before taking her life at her Davenport family home. The coronial inquest into her death has identified multiple shortcomings in Deborah’s care and “a number of matters connected with the issue of suicidality in patients presenting in a country hospital that are ripe for change”.With a documented history of self harm dating back to 2008, Mr McKenzie believes more could have been done to prevent his daughter from taking her own life.The McKenzie family are fighting to be heard so that positive change can come from their personal tragedy.“If there’s something we can get from this it’s that we don’t want to see other people suffer from losing their children,” Mr McKenzie said.“This is an opportunity for us all to work together to see change so that people can get the right treatment, because there’s a clear lack of service and a lack of investment in our town around people’s health.”FAMILY: Malcolm and Dorothy McKenzie have built a garden in the their Davenport home as tribute to their daughter Deborah.Hospital management ‘suboptimal’Following the inquest into Deborah’s death the Deputy Coroner has been scathing of the management of her care at Port Augusta Hospital, labelling it as “suboptimal” at best.On March 11 2013, Deborah was rushed to Port Augusta Hospital where she was admitted and treated by the rostered general practitioner following a suicide attempt.Deborah was listed as being of ‘moderate risk of self harm and suicidality’ during her nursing assessment.According to the risk domain scoring matrix, a high risk of suicidality involved psychiatric diagnoses with severe symptoms or an acute precipitating event.The coroner said that in Deborah’s case “one would have thought that there had been such an event”.”They asked if she had a mental health history and they didn’t go back to find out her records, if they had of gone back through her records they would have seen that she was really at high risk of hurting herself.”- Malcolm McKenzieDeborah’s incorrect risk assessment meant there were no suicide precautions implemented in her treatment.The next morning Deborah received another “superficial and inadequate” assessment from a mental health nurse, resulting in her being discharged without being attended to by a doctor.Although hospital records indicate Deborah had a family member present with her at her time of discharge, this person has never been identified.Deborah’s brother Zaheer McKenzie, a respected member of the Leigh Creek police force, saw his sister by coincidence in the hospital car park immediately following her discharge and said he did not see her with anybody.Mr McKenzie was disappointed that the hospital had not reached out to him or his wife, despite their obvious concern and involvement in their daughters life.“I know she was over 21, but they didn’t ring me and my wife to say she had been released, she was vulnerable and she needed someone with her,” he said.As part of the inquest Professor Robert Goldney, an Emeritus Professor Professor in Psychiatry at the University of Adelaide with over 40 years of clinical experience, gave an expert review of Deborah’s management at the Port Augusta Hospital.Professor Goldney expressed a firm view that Deborah should have been kept in the hospital longer than she was by means pursuant to detention under the Mental Health Act 2009.The coroner concluded that Deborah’s death would have been preventable if “she had been stopped, by whatever means, from leaving the Port Augusta Hospital.”“They didn’t take her seriously otherwise they would have kept her in there of they would have had a release plan,” Mr McKenzie said.“I want people to be accountable, they’ve got a duty of care for everyone.”PORT AUGUSTA HOSPITAL: The coroner has made 12 recommendations pursuant to the death of Deborah McKenzie, many of those relating to the lack of mental health staff in regional hospitals.The gap in regional healthcare According to a report released by the Royal Flying Doctor Service (RFDS) in June, suicide rates in rural and remote Australia are twice as high as in metropolitan areas. The report also found that compared to city people, mental health services are only available at a fifth of the rate to those living in regional Australia.At the Port Augusta hospital there is no psychiatry department or unit with psychiatrists, registrars or mental health nurses.The void is filled by general practitioners and mental health liaisons who are unqualified to provide adequate and robust assessment.Largely represented in 12 of the coroners recommendations was the need for Port Augusta — as a regional hub to many remote areas — to have a fully-fledged mental health team compl
Source: Deborah McKenzie: ‘failed by the regional healthcare system’ | The Transcontinental