There is so much to deal with emotionally with the death of your child. Add in suicide, and there are many more layers to our grief. Then add in negligence in your child’s care including many lies/obfuscatingthe truth from your child’s carers that you trusted and it gets very messy.
It is so hard living with how preventable my 14 year old daughter, Soraya’s, death was.
Soraya tried so hard to get help, but the “help” she received at our zoned public CAMHS (Child and Adolescent Mental Health Services) unit just made it worse.
There were so many broken promises and so many lies across the people we dealt with. In fact, no one in the many healthcare professionals we talked to over a nine month period even told us she was suicidal while they document how she had suicidal ideation for 3+ years and many other signs that she was at great risk of suicide.
She died 10 days after a 10-day inpatient stay where they sent her home acting like she was better, even though the notes in Soraya’s medical records paint a totally different story. They have not even been able to confirm if the discharging psychiatrist talked to her for more than a few minutes.
It will take another, L O N G article to describe all the faults we feel happened with her care. This article is focused on our search for accountability, transparency and our quest for change in the health system so more children don’t die.
Despite being raised as a sentinel event (defined in our state of Victoria as an “unexpected and adverse event that occurs infrequently in a health service entity and results in the death of, or serious physical or psychological injury to a patient as a result of system and process deficiencies at the health service entity”), we still don’t have our questions answered, as required, and they won’t share the full report, or any documents beyond a 2.5 page overview, from their review of her care which concluded in July.
I have talked to Safer Care Victoria, who is meant to oversee this process, the Chief Psychiatrist of Victoria and the Minister of Mental Health. All I get is referrals back to the Austin for more information. Who won’t give it.
The Chief Psychiatrist herself even told me to basically blindly trust the Austin did the review properly because “everyone in the system wants to do good and to prevent anyone’s child from suffering or dying. We want to address every tragedy as best we can for the greater good.”
If that was truly the case, they would share the review with me, and they would have had recommendations that could lead to real change. More importantly, Soraya wouldn’t have died. All they had to do to change that outcome was to tell me what my 14 year old CHILD was saying.
There was no issue of privilege, yet they hide behind it.
To tell me to just trust that they care shows absolutely no understanding of what the health system did to my family. All it shows me is that she didn’t read my email and my attachments. She didn’t watch the video of Soraya herself saying she didn’t want to die but she had no choice. No one would help her, and they didn’t believe her.
But according to the Chief Psychiatrist, this is a health system we should trust.
I have also complained to AHPRA and the Mental Health and Wellbeing Commission (MHWC). AHPRA investigates complaints against individual health professionals and MHWC against publicly funded mental health and wellbeing services in Victoria.
AHPRA won’t investigate until MHWC have finished. MHWC investigates after the coroner has finished (which is likely to take 2-3 years in our case).
It feels like all these services hope that if they make us wait years, we’ll disappear. In the meantime, more children will die in this broken system.
In relatively good news, MHWC has decided to use Soraya’s case as the first one they do at the same time as the coronial investigation. I believe this is because it’s so clear that there was negligence in her care. But can you believe that they can only access any documents from the review done at the Austin into Soraya’s care if the Austin themselves give permission?!!!
I can’t even give them the one, tiny document I have which is an overview of the review report unless the Austin says yes.
It all starts to feel very corrupt and it’s impossible to believe that anyone in the health system is trying to change our disgustingly insufficient mental health system.
I really hope no one you love ever needs it.
Soraya wanted to be a pediatric nurse working in mental health. I know she would want to help other kids who struggle like she did. She would want me to advocate for change.
But most of all, I know she wanted to be alive. She just couldn’t live with the pain she was experiencing. Her carers knew this and did nothing to prevent it.
Please share this post. Maybe it will get back to someone who can actually make someone in this broken system tell us what happened, give us the review and at least show some respect and care to our daughter who deserved so much more.
Even better, maybe it’ll make someone institute real change that can save young lives.
She should be dancing in her dance concerts later this week as she has where possible since 2016. She should get to cheer for her brother at the concert. She should get to be here for all her friends and family who love her and miss her so much.
But instead she is gone forever and the system doesn’t even care enough to stop it happening again. Or show us the dignity and respect we deserve by answering our questions.
Safer Care Victoria did respond to my most recent request after publishing this to say they will look into whether the correct process was followed by the hospital in the review process, but they can’t review the review itself which remains the property of the hospital.
If you have dealt with the health system in trying to advocate for transparency and change and have any tips, please reach out.
This absolutely breaks my heart. I’m so sorry for your family’s loss of Soraya. From what I’ve read on this blog she was an amazing empathic person who brought so much love and light to many. It’s devastating that her light was extinguished. Although I haven’t lost a child, I lost a parent to suicide. I understand the all consuming need for information to understand the why and how. I remember the coronial process, the FOI requests back and forth with agencies was all consuming until we received the coronial report. I would assume as Soraya would have been classified as “in care” there will be an inquest. Hopefully the coroner pushes back on Austin Health. Your family will have the opportunity to send your concerns to the coroner. Do you mind me asking, has Soraya’s matter been assigned to Coroner Ryan?
I’m in two minds about what you’ve described as your experience with The Austin.
On one hand I’m shocked that this was able to occur and how Soraya and your family were let down in such an unimaginable way.
On the other hand, my experiences with The Austin paeds ED and outpatient ICYMHS (not inpatient CAMHS) has been so inconsistent in messaging between the two that it’s been dismissive at times. So I’m not as shocked as I should be.
Our family is suicide bereaved, the impact on my now 13 yr old daughter resulted in a referral to ICYMHS 18 months ago. The outpatient service tells us that after hours and in crisis to present to ED, but when we have the ED doctors were dismissive and acting like her attempts are inconvenient to them. The last time telling me in front of my then 12 yr old that unless she has ingested poisons or is actively dying don’t present to ED again as we already had the support of ICYMHS which is more than others. She feels that no one at the hospital cares what happeneds to her, or believes her that she’s in crisis when she’s distressed. About 6 months ago ICYMHS changed their tune about the recommendation of making her inpatient when in crisis and told us that we need to avoid it due to her young and impressionable age. Which I agree with, I’ve seen her interact with other unwell kids, she tries to compete with them. Where the process is painfully slow more than 12 months of weekly appointments and assessments until our daughter received an official diagnosis and in turn targetted help. Private psychology and psychiatry wasn’t better either. 2 years of counselling, EMDR therapy for trauma, a psychiatrist who medicated her and then refused referrals back for medication reviews, we had no choice but to focus on outpatient care from The Austin. But 12 months of assessments before getting the actual support needed has been so drawn out. I feel like when families are in crisis they can’t see, as they don’t know, what the appropriate level of care should be.
Thank you for advocating for Soraya, your family and countless other families who rely on the public health system and aren’t getting what is needed.
That is so awful, Stephanie. I’m sorry about your father and about the “care” your daughter has received. Which does not shock me at all.
We were first involved with the outpatient team 9 months before Soraya died. They spent months assessing her and promised both her and us that they would give us so many forms of help. In the end, they only gave us one family session!! And didn’t even tell us she was still suicidal or anything else she said. When we got her medical records after she died, we found out their assessment recommended so many different things, but they not only didn’t do this but didn’t tell us so we could get help elsewhere.
To make this worse, I received the review into her death after writing this. It said they didn’t see her at that time because we opted to go private instead! A complete lie. We didn’t even know we should have as they never told us anything was wrong. While they assessed her as “moderate to high suicide risk”. She was 13 when we started this process. We had no idea they weren’t telling us things like this and thought it meant she must be ok if they wouldn’t see her.
In this full review report, the continuously marked their communication as satisfactory. So don’t trust what they tell you at all as they themselves think it was fine to treat Soraya (and us) like this.
I found a video journal Soraya had kept after she died. When the Austin refused to see her at that point is when she gave up for good and decided she needed to die as she felt no one believed her and no one would ever help. It is disgusting.
I don’t know which coroner we are assigned to.