Finding into death of GRA
Demographics
23y, male
Date of death
2024-08-13
Finding date
2026-07-10
Cause of death
Plastic bag asphyxia
AI-generated summary
GRA was a 23-year-old who died by suicide on 13 August 2024. He had depression, anxiety, and suicidal ideation since age 21. The mental health team (HOPE) discharged him in April 2023 when thoughts improved, recommending a local psychologist. Unable to access one due to cost, he used BetterHelp, an overseas online counselling service. After incarceration for child pornography (June–August 2024), he received no coordinated follow-up. When informed on 12 August he would be registered as a sex offender, he disclosed his offences to his sister and died by suicide the next day. Critical failures identified: overseas telehealth providers operate outside Australian regulation; continuity of care failed—discharge information never reached the overseas counsellor; vulnerable, suicidal patients need robust in-person multidisciplinary care, not unregulated online services. The coroner recommended developing consumer guidance and public awareness campaigns about online mental health service limitations and requiring public mental health services to discuss risks when discharging vulnerable patients.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- depression, anxiety, and suicidal ideation
- incarceration for child pornography offences
- registration as sex offender
- breakdown in continuity of mental health care following discharge from HOPE
- reliance on unregulated overseas online counselling service without adequate safety protocols
- lack of mental health follow-up coordination after release from prison
- alcohol consumption (blood alcohol concentration 0.13 g/100mL)
Coroner's recommendations
- AHPRA should develop and publish a resource specifically designed for consumers of online or virtual mental health care services, including information about limitations of overseas providers such as limited knowledge of Australian mental health systems, limited ability to exchange information with existing health care providers, and inability to link with broader support services
- AHPRA and the Commonwealth Secretary of the Department of Health, Disability and Ageing should develop a public awareness campaign about the limitations and potential risks of virtual mental health care services, particularly when provided by practitioners based overseas
- The Chief Psychiatrist of Victoria should develop a guideline for public mental health services about the safe use of online or virtual mental health care services by consumers, including the need for public mental health services to discuss the use and risks of such services with consumers during discharge planning and at the point of discharge
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