Mental health system 'not to blame' for suicide

The supervision, treatment and care of a severely depressed Perth woman before she flew to Mexico and committed suicide was not optimal, but was not below accepted practice at the time, a WA Coroner has found.

The 39-year-old woman, known as Ms D, travelled to Mexico in April 2008 after she discharged herself from King Edward Memorial Hospital earlier that month and was placed on a community treatment order.

She had been made an involuntary patient in February but her involuntary status was later removed by the Mental Health Review Board despite hospital staff having found evidence of her suicide plan.

A coronial inquest into her death was held earlier this year.

In findings handed down today, acting State Coroner Evelyn Vicker found the woman, who was deeply resistant to conventional medication and hospitalisation, "well knew how to mask her real presentation with a facade of seeming to comply with treatment".

Ms Vicker said the woman used a hearing before the MHRB "to convince the members she was quite rational and able to make appropriate choices for her wellbeing".

Ms Vicker said: "She effectively convinced the MHRB she would be better off without the restrictions imposed by her involuntary status".

Ms Vicker said the decision to allow the woman to be treated in the community was "entirely understandable".

The inquest heard the woman withdrew consent for her sisters to be provided with information and the sisters felt that if they had not been so excluded, "they would have been in a position to intervene successfully in the deceaseds suicidal ideation for long enough to get her through the crisis around her death into a safer space".

Ms Vicker said the woman would have understood it was very unlikely her treating clinicians would have involved her sisters due to their perception it would affect her progress.

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Mental health system 'not to blame' for suicide