Inquest into deaths of Barrett Centre young people begins

Today was the first day of the inquest into the tragic deaths of Talieha Nebauer, Will Fowell and Caitlin Wilkinson Whiticker.

Being overseen by Deputy State Coroner John Lock, the entire process is scheduled to run across a number of weeks, with a number of the parties (i.e. individuals, groups, government bodies etc.) directly involved in the Barrett Adolescent Centre Commission of Inquiry (BACCOI) also represented at these proceedings (in some cases by the same legal counsel). Each young person’s situation will be scrutinised over several days before a final procedure where the collective issues will be examined so as to address the need to consider “opportunities to improve management of the risk of suicide“, as noted in the prioritised issues listed on the Inquest Schedule.

It has been a long and difficult wait for the families who lost young people more than four years ago. Many of the others involved – politicians, those involved in professional roles etc. – have been able to go on with their lives since the days in 2014 when those close to Talieha, Will and Caitlin were forced to face an existence without those they loved. And then again then since the procedure and conclusion of the BACCOI. But since the COI took a clear position to not encroach on any areas that could relate to an inquest – those being in the Coroner’s jurisdiction – Justice Margaret Wilson was not in a position to provide families with the answers they have needed. In fact, due to the time constraints of the COI, it was deemed necessary to ‘draw a line in the sand’ as regards a timeframe for consideration of consequences of the closure:

“This temporal limitation meant that the Commission’s factual inquiry started at the beginning of the transition and ended around one month after the transition client’s discharge from the BAC. The Commission’s terms of reference, and its factual inquiry, do not extend to a consideration of the following matters:

  • the immediate cause or root causes of the deaths of the three young people who died in 2014 who had formerly been patients of the BAC
  • whether those deaths were caused by or contributed to or affected by the closure of the BAC in early 2014
  • whether those deaths were caused by or contributed to or affected by the transition arrangements or the adequacy of care provided by the various receiving services.

Those are matters for the Coroner.”

Barrett Adolescent Centre Commission of Inquiry Report
p 385 of printed document, p 398 of pdf (
Click here to access)

This earlier post may provide more clarity on the relation of the findings of the COI to the coronial inquest. But it is clear that the Coroner’s office, in holding a combined inquest procedure for the three young people, has determined that the closure of the Barrett Centre must be examined as a factor in the deaths as, tragically, that is the key event that links all three.

This will be an extremely challenging process for those who have been emotionally affected by the losses of Talieha, Will and Caitlin and by the closure of the Barrett Centre. To relive trauma numerous times is a debilitating experience and to have to do so in a formal legal arena where events, accounts and perspectives will be questioned by those defending the positions of other individuals and groups will be gruelling.

It is rare to find anyone in our communities these days who has not been impacted by mental health issues in some way so we know that many people will be feeling for those whose lives have been changed dramatically because of severe and complex mental health issues in adolesence. And particularly now for those who lost three treasured young people. So perhaps, as the news reports are filed and the lawyers quoted, we should all keep in mind that this inquest is about 

TALIEHA

WILL

and 

CAITLIN

There are many people who have never, and will never, forget them.

So may this process provide the answers that these three deserve.


Note: Coverage by the ABC Radio’s ‘The World Today’ program can be listened to by clicking here.

All reporting on this and on other issues related to severe and complex mental youth health can be found on our In the Media‘ page.

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A Budget Boost – its implications for the Future … and the Past

A BLOG POST

The announcement of just under $70 million dollars to not only proceed with the establishment of the new extended treatment and rehabilitation facility at Chermside but to provide two new Step Up Step Down facilities and two new Day Programs to support young people with mental illness (online summary at the ABC website here) demonstrates the current government’s ongoing commitment to those who have been sadly overlooked in the past. Bi-partisan support for these positive moves would begin to ensure some long-needed stability and security for the futures of those in this most vulnerable of groups.

An adolescent extended treatment facility (AETF) fills a dangerous gap in service provision and Step Up Step Down and Day programs are vital in the full continuum of treatment and support options that are required to meet the needs of all young people with mental health issues. Extended inpatient treatment has proven essential for those young Queenslanders with severe and complex issues who have failed to make progress accessing community-based care and outpatient/intermediate care service options. The additional new programs will – if they are accessed in a timely way – provide some young people with the help needed to circumvent a stay in a residential facility. AND for those for whom extended inpatient care is essential, they will ensure that transition from one environment to another is gradual and fully supported according to the individual needs of the young person. Those affected by youth mental health issues across Queensland will be hoping that these kinds of service options will become readily available across the state. As community-based care remains the optimal environment – when the circumstances are right – then all communities must have access to every level of treatment and support.

The plans for the new facilities and programs have come from the process that commenced following the government’s commitment to act on all the recommendations from Justice Margaret Wilson’s report following the BAC Commission of Inquiry. Queensland Health then undertook to utilise a “co-design” process i.e. where bureaucrats, clinicians, specialist architects and other professionals work alongside consumers and carers to plan services that will be most effective. (Acknowledging that expertise lies not only in professional knowledge and practice but in lived experience is currently seen as innovative but should inevitably become standard procedure. Omitting those with practical, pertinent and comprehensive knowledge of the lived experience can only add an important dimension to planning for services in any area.)

Those young people (current and former) and family members who have taken part – and continue to be dedicated to – the process of genuine collaboration have demonstrated a level of commitment that is rare. People whose lives are affected by severe and complex mental health issues find themselves most often in situations where days and nights are to be survived moment by moment; plans are seldom made and often abandoned; and significant trauma, suffering, isolation and emergency management of the effects of illness must be regularly dealt with. And during recovery, the right approach for so many will be to look forward, to put strategies in place to navigate through daily challenges and to resist rumination on issues of anxiety and trauma. So participation in design of future services may be something that could be extremely problematic for the stability of some people’s mental health. There is great understanding throughout the mental health community for all who have suffered to make the right choices that will best support healing and not put mental health at risk and equally, there is deep gratitude for those able to put time and effort into a co-design process, sometimes at personal emotional risk.

And then there are those for whom looking forward provides a view with a void that can’t be filled – the families and communities who have lost loved ones will be experiencing mixed emotions at this announcement. The families of Talieha Nebauer, Will Fowell and Caitlin Wilkinson Whiticker will no doubt be relieved that there continue to be moves to ensure others might not have to suffer the personal tragedies that still shape their lives. Justine Wilkinson, herself a key participant in the co-design process, has told the ABC in relation to the budget commitment (particularly in relation to the continuation of planning for the Chermside AETF):

That’s absolutely fabulous, but this change has to continue, this is just the beginning and it has to be just the beginning. … We need to keep feeding these changes and innovations down the system to pick up young people before they get to that point.

However, we must recognise this news can only be bittersweet for those whose young people did not have the benefit of a government with such a strong commitment to confront youth mental health issues and to listen to those affected to order to provide the needed services. So our thoughts must also be with those whose bereavement continues as we hear this news. We must assure them that we will never fail to remember those who will not have the opportunity to access planned new services and we will continue to support those families for whom an inquest may provide some answers but will inevitably be a traumatic process and will never ever restore what they have lost. Talieha, Will and Caitlin and those that will continue to feel their absence from their lives are always in our thoughts.

The complexity of severe adolescent mental health issues is reflected in the reactions of those with lived experience to this positive budgetary news. There is relief, hope and gratitude but there is also caution and uncertainty from those who have experienced innumerable disappointments and who know that politics can play an inappropriate role in what is necessary in service provision across our communities. And there is renewed reflection on the tragic losses that will continue to impact people’s lives, whatever the future holds.

Severity and complexity in relation to mental health issues is not confined to a small group of young people. It is pervasive. It is challenging. And so it has become a situation that a significant proportion of the population have to live with and an issue that every single one of us must acknowledge.

The support that has been provided to the former Barrett families throughout the community has demonstrated that the capacity to care is our greatest strength. It is the strongest choice that any human being can make and it is undoubtedly the most rewarding. So with, gratitude for all everyone has done to lead us to a day when $70 million is committed to the next generation of Queenslanders, it’s hoped that the future contains not just all the services required but the ongoing support of an impressively caring population.

AN INQUEST … families still waiting

A BLOG POST

Talieha Nebauer passed away in April 2014
Will Fowell died in June 2014 and
Caitlin Wilkinson Whiticker took her life in August 2014

Two of those young people were in the care of the state when they took the actions that would end their lives. The other was living with family who had no access to any information on that young person’s treatment plan or assigned clinicians; state of mind and attendance at sessions; or the appropriate behaviour and support to be adopted by those close to her.

Prior to the closure of the Barrett Centre, families had the security of knowing that their loved ones were so well supervised that they would be safe from the fatal outcomes that their mental health issues could lead them towards. They knew that they were in an environment where they were surrounded by friends who’d look after them, who’d demonstrated the kind of caring that would at least help to nullify the feelings of isolation that had previously plagued them. And, for many, there was the hope that long-awaited progress brings – that one day, they would be leading independent lives in the community with all that things that that entails – study, work, social activities, sport, relationships, a family of their own …

but that ended as the turbulent years of uncertainty and decline led to the disintegration of that understanding community. Young people found themselves in unfamiliar places, sometimes surrounded by adult patients and expected to bear the burden of levels of self-sufficiency that they had no experience with; or living in the community and wielding the rights and authority of adulthood without the maturity or capacity to have such a huge responsibility.

April, June, August 2014.

And still no answers for their families. 

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