A coroner has found that the decision to grant leave to a mental health patient who later took her own life on Christmas Eve 2021 was “unwise,” after discovering her family had not been informed of a recent suicide attempt.
Gabriella Kathleen Ann Freeland, known to her family as Kate, died at her home in Auckland just one day after her father collected her from the psychiatric in-patient ward at Palmerston North Hospital. The 28-year-old had been under compulsory treatment after a series of severe mental health episodes and a suicide attempt only a week earlier, RNZ reported.
In her findings released on Monday, Coroner Janet Anderson said the decision to grant Kate home leave was concerning, and that her father had not been properly informed about the severity of her condition.
“Robert Freeland was not properly informed about the seriousness of Gabriella’s situation, and he was not provided with information that might have helped reduce the risk of her ending her life while she was on leave,” the coroner wrote, as reported by RNZ.
Kate’s brother, Jared Freeland, who found her body, said the family hoped her death would drive improvements in New Zealand’s mental health services, describing the current system as a “national disgrace.”
RNZ reported, Kate’s mental health struggles intensified after her mother died in 2017. Diagnosed with ADHD in childhood, her condition deteriorated over time, with alcohol abuse, erratic behaviour, and multiple suicide attempts. She was treated for psychosis and schizophrenia in 2021, but later re-diagnosed with ADHD just days before her discharge.
After a suicide attempt on 18 December 2021, Kate was readmitted to hospital but discharged again five days later to spend Christmas with her family. Her father said he was told she had been readmitted because her medications were “wrong”, but he was not aware of her recent suicide attempt.
The MidCentral District Health Board conducted a review, which found that Kate’s tendency to downplay her risk was not adequately considered and that staff were unsure whether her father fully understood her recent history. Reviewers said the decision to grant leave just days after a suicide attempt and a diagnosis change should have triggered further risk assessment, reported RNZ.
The psychiatrist who approved her leave said it followed “an intense five days of assessment, treatment, and observation” and was supported by both the patient and her father. “Despite that, and the team doing their best, a tragic outcome no one wanted followed,” he said, adding that the incident deeply affected the clinical team, RNZ reported.
Expert psychiatrist Associate Professor Ben Beaglehole told the coroner the rapid change in diagnosis from schizophrenia to ADHD may have influenced the decision to allow leave and reduced the team’s vigilance. He noted that inpatient units often operate at full capacity, making such cases complex and difficult to manage.
Coroner Anderson concluded that while it was not possible to say definitively that Gabriella would have survived had she not been discharged, the decision to allow home leave was “unwise” given the short timeframe after her suicide attempt.
She also recommended that Health NZ:
Health NZ has since introduced new procedures for assessing patient risk and ensuring families are better informed before leave is granted.