Coronial
TASmental health

Coroner's Finding: Mead, Liam - Ruling on Evidence

Deceased

Liam Peter Mead

Demographics

male

Date of death

2017-03-07

Finding date

2019-08-02

Cause of death

not_stated

AI-generated summary

Liam Mead, a teenager, died on 7 March 2017, two days after discharge from an inpatient psychiatric facility in Victoria. He had experienced functional deterioration in late 2016 related to psychosocial stressors and was treated for mental illness including inpatient care. This ruling addresses the admissibility of expert evidence regarding adolescent mental health services in Tasmania. Professor McGorry's evidence indicates that treatment in a geographically remote location away from family and social supports creates disadvantages, and that intensive post-discharge follow-up with the same treating team located in Tasmania might have altered the outcome. The coroner ruled that the adequacy and availability of adolescent mental health services, including inpatient facilities and intensive community follow-up services, are relevant circumstances to the death and appropriate matters for inquiry, particularly if suicide is established as the cause.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

psychiatrypaediatrics

Error types

systemdelay

Clinical conditions

mental illnessdepressionsuicidal ideation

Contributing factors

  • discharge from inpatient mental health facility located interstate, away from family and social supports
  • expressed suicidal thoughts on many occasions prior to death
  • inadequate post-discharge follow-up care
  • treatment at facility geographically remote from home
  • lack of dedicated adolescent inpatient mental health facilities in Tasmania
  • limited specialized mental health services for complex adolescent cases in Tasmania

Coroner's recommendations

  1. Development of a comprehensive youth mental health plan in the Tasmanian health system ranging from acute and tertiary inpatient beds through sub-acute, stepdown residential units, mobile home treatment teams, assertive community treatment teams, and skilled multi-disciplinary teams linked to headspace centres and primary care
  2. Establishment of purpose-built dedicated adolescent inpatient mental health facilities in Tasmania
  3. Implementation of intensive daily outreach follow-up services for adolescents following discharge from inpatient care
  4. Development of youth-friendly community-based mental health services
  5. Improvement of coordination between inpatient and outpatient mental health care
Full text

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