Gabriella Freeland was granted leave from the Palmerston North mental health unit. The following day, she died by suicide. Photo / Supplied
WARNING: This story discusses suicide and may be distressing for some readers.
A woman had attempted to take her own life less than a week before she was released from an acute mental health unit.
A day after being given leave, Gabriella Freeland, known as Kate, tried again and died by suicide on Christmas Eve, 2021.
Now, a coroner has labelled the move to release her as “unwise” considering her recent suicide attempt and a change in diagnosis.
Freeland’s is the latest in a spate of deaths of patients either at the mental health inpatient unit at Health New Zealand’s Palmerston North Hospital, or who had been released.
Earlier this year, a coroner who investigated a patient’s 2014 death said the unit was “not fit for purpose” and urged a new one open as soon as possible, which it did in September.
For 28-year-old Freeland’s family, the move came too late.
“Similar events have happened before and every time the coroner makes a report, gives their recommendations and hopes it won’t repeat,” her brother Jared Freeland told NZME.
“And then it seems the exact same thing happens again.”
Jared said their family was never told about his sister’s suicide attempt.
If they had, they would have supervised her more carefully and their approach to her care would have changed, he said.
“We were not prepared in any way for what happened; we didn’t expect it,” he said. “They never told us what was going on.”
While Jared was unsure whether his sister’s life could be safeguarded long term, acknowledging she couldn’t be “held in a ward forever”, he felt the unit had let her down in the interim.
“I feel the ward had a duty of care to their patient and the decisions they made breached that.”
He hoped her story could help others by not assuming that because a family member was in care, they were safe from harm.
“I don’t think many people understand how lacking our mental health services are.
“We’re a first-world country; we’re supposed to have a first-world level of care but our mental health services don’t reflect that.”
Today, Coroner Janet Anderson released her findings into the death of Freeland after an earlier inquest.
According to the findings, Freeland grew up in Auckland and was diagnosed with ADHD as a child, for which she took medication.
Her mother died in 2017 after a battle with motor neurone disease and Freeland’s life subsequently fell apart.
She struggled with alcoholism, depression and other mental health issues.
Jared stressed his sister was an intelligent, competent woman and it was the death of their mother that was the catalyst for her mental health problems.
Freeland spent time homeless and was picked up by police in 2021 while threatening to kill herself.
After being assessed by mental health services, she was admitted to Palmerston North Hospital’s mental health inpatient unit, where she received compulsory treatment under the Mental Health Act.
A psychiatric report found she was paranoid, evasive, guarded and suicidal.
During her time in the unit, Freeland was unpredictable and asked staff to provide her with equipment that she could use to take her own life.
She was treated with a long-acting, anti-psychotic medication and was released to a flat owned by someone with links to mental health services.
Within two weeks, her psychiatrist found Freeland had not been taking her oral medication and supervision was arranged to ensure she took it.
By December 2021 she was assessed as being a low risk of suicide or self-harm and arrangements were made for her to travel back to Auckland to spend time with her family over Christmas.
But before she could make the trip, she attempted suicide at her flat and was readmitted to the unit.
Instead of her visiting Auckland, her father Robert Freeland went to Palmerston North where he met with her doctors.
He told them he was concerned that if he took her to Auckland she would be at home alone during the day while he was at work.
Robert maintained he wasn’t told about his daughter’s recent suicide attempt and she was released on leave to return with him to Auckland.
Freeland’s doctor said he was hopeful she would enjoy Christmas with her family.
Robert said the following day they had a great time out, shopping together and having lunch.
Freeland went out for a few hours, then came back to the house, spoke with her brother and went to her bedroom.
About two and a half hours later, she was found dead in her room.
After her death, the MidCentral District Health Board carried out a review and found Freeland tended to try to hide her suicide risk.
The review found staff were critical that Freeland had been granted leave from the unit and were not confident her father knew about the suicide attempt.
Coroner Anderson has now found letting Freeland leave the unit so soon after a serious suicide attempt and a “significant change in clinical diagnosis” was “unwise”.
The coroner had been advised Freeland was diagnosed with schizophrenia while in the unit, but that diagnosis was later determined as incorrect and the earlier ADHD diagnosis remained.
“There was no opportunity to properly consider the impact of the changed diagnosis or the recent alteration in medication before Gabriella left the unit with her father.”
Coroner Anderson also found that Robert was not given appropriate information when he took his daughter home for Christmas.
This included information that would have helped reduce her access to the means to take her own life, warning signs to look out for and supervision requirements.
“While there is uncertainty about exactly what he was told, it is clear that he was not aware of the specific details of Kate’s serious suicide attempt only several days prior,” the coroner said.
“Neither did he have any understanding of the potential risks associated with his taking Kate home for Christmas.”
The coroner also found that Freeland’s risk status didn’t appear to have been re-evaluated before it was decided she could leave the unit, again, despite her recent suicide attempt.
Since Freeland’s death, the unit has made significant changes to its processes, Coroner Anderson found.
But she recommended that it still undertake a robust review of its in-patient culture, review its resourcing and undertake regular audits of its new policies.
Palmerston North Hospital’s Ward 21 has been the scene of a spate of deaths in the past 11 years, prompting a comment from another coroner this year that the unit was “not fit for purpose”.
Shaun Gray took his own life at the unit in 2014, followed months later by 21-year-old Erica Hume. Two inquests were held in Palmerston North eight years later, of which only Gray’s findings have been released so far.
Then, in 2017, Chelsea Brunton and Simon Oakley were granted leave from the unit and both were found dead within a week of leaving.
A new unit was scheduled to open in 2022 but did not open until September this year.
Health New Zealand’s chief medical officer for MidCentral, Claire Hardie, said that on behalf of the organisation she was sorry for Freeland’s loss, and extended her condolences to her family.
“We acknowledge the Coroner’s comments, noting the significant changes that MidCentral has made since Gabriella passed away,” Hardie said.
“These include changes to policies and procedures and improvements in family engagement processes. There is now a high level of engagement and communication between our clinicians, and we strive to ensure our clinicians feel supported by one another.“
Hardie said the coroner’s recommendations reflected changes already made by Health NZ and staff and patients would be transferring to the newly-built unit, after which an audit on culture and staffing would be undertaken in the new year.
Jeremy Wilkinson is an Open Justice reporter based in Manawatū, covering courts and justice issues with an interest in tribunals. He has been a journalist for nearly a decade and has worked for NZME since 2022.