Coronial inquest examines patient suicides at Brisbane hospital mental health unit

A coronial inquest into a cluster of three patient suicides within a seven-month period inside the mental health unit of a major Brisbane hospital has been told it remains at "over capacity all the time".

Coroner Megan Fairweather is probing the deaths of Barry Ellery, 77, Miranda Meyer, 37, and Kendal Quicke, 31, at The Prince Charles Hospital between May and December 2023.

She is examining the appropriateness and adequacy of the mental health care and treatment provided by the Metro North Hospital and Health Service at the time of the deaths.

A treating psychiatrist of one of the patients, whose name is the subject of a non-publication order, told the hearing in Brisbane that at the time of the deaths, mental health unit patients had to regularly be admitted to the thoracic ward.

The mental health unit has two wings with 60 beds, but the psychiatrist said it was common for up to 12 mental health patients to be admitted to the thoracic ward at any one time in 2023.

She said while improvements had been made since the suicide cluster, and the thoracic ward was no longer used for psychiatric patients, the mental health unit still had "a major problem with bed capacity".

On the opening day of the inquest, Ms Fairweather heard details of Ms Quicke's death on November 12, 2023.

The trainee psychiatrist involved in her care, whose name is also subject to a non-publication order, told the inquest of having an inpatient workload of about 11 to 13 at the time of the suicide deaths. The recommended numbers are about four to five.

His consultant psychiatrist told the inquest the trainee workload had eased since Ms Quicke's death.

She said she reviewed Ms Quicke on November 2 after her admission with major depressive disorder alongside a "range of trauma-related symptoms which appeared to be chronic in nature".

Ms Quicke also had diagnoses of attention deficit hyperactivity disorder, autism spectrum disorder and borderline personality disorder.

But the psychiatrist said Ms Quicke "presented as someone who was motivated to follow advice and engage in a plan to improve her mental health".

"I felt Kendal had a very positive prognosis," the psychiatrist said.

"I felt she was going to do very well. I felt hourly visual observations are appropriate."

The inquest heard that Ms Quicke's observations were changed to 15-minute visual observations by nursing staff on November 5 but neither the treating psychiatrist, nor her trainee, recalled ever being advised of this before the suicide.

On November 7, after her case was reviewed at a multi-disciplinary team meeting of doctors, nurses and allied health staff, Ms Quicke was considered well enough for general observations, meaning checks every four hours.

She took her own life five days later.

The inquest comes after an external health service investigation triggered by the deaths found the mental health wards at The Prince Charles Hospital were "no longer fit for purpose" and posed safety risks that needed to be "urgently" addressed.

The review, handed down in 2024, found the two wards were "not in keeping with contemporary guidelines for mental health facilities".

"[The facilities] are not conducive to mental health recovery and wellbeing for consumers, and they pose a number of potential safety risks for both consumers and staff," the review said.

Ms Fairweather told the court today her role as coroner was a "fact-finding exercise".

"It's not my role to cast blame."

She will consider whether any additional changes to the delivery of mental health services within the Metro North Hospital and Health Service should be made.