Source: Radio New Zealand
A coroner has found the death of Liam Booth, who was sent home from hospital in a taxi after threatening to take his own life, could not have been prevented.
Liam Booth was sent home from hospital after threatening to take his own life. (File photo) RNZ / Dan Cook
Warning: This story discusses suicide.
A coroner has found nothing could have been done to prevent the death of a 21-year-old Christchurch man who was sent home from hospital in a taxi after threatening to take his own life.
Liam Booth was found dead in Beckenham in October 2017. A coronial inquiry was opened that year followed by a 2022 inquest as a result of his father Geoff Booth’s concerns about the care his son received from the then-Canterbury District Health Board (now HealthNZ Canterbury).
Geoff Booth spent years seeking answers from health authorities, spoke out in the media about his son’s death and on behalf of other bereaved families and ran unsuccessfully for the District Health Board in 2019 to raise awareness about suicide and advocate for better mental health services.
In findings released on Monday, eight years after Liam Booth’s death, Coroner Bruce Hesketh rejected several of Geoff Booth’s concerns, including that his son’s level of care was unsatisfactory, and that he should not have been discharged from the emergency department and instead should have been compulsorily admitted to hospital.
A Serious Event Review conducted by the DHB after Liam Booth’s death found the hospital could have spoken to Geoff Booth before discharging his son, that his family were not involved in his discharge plan, some documentation was lacking and there was a lack of information given to the family about support available.
The DHB’s then-chief of psychiatry wrote to Geoff Booth in September 2018, apologising that Liam Booth died under the care of the mental health service, and committing to implementing recommendations from the review, the Coroner noted.
In their evidence, Liam Booth’s parents described difficult periods managing his behaviour from a young age, including low mood, a diagnosis of oppositional defiance disorder, acts of aggression and threats of self harm.
A 2008 incident in Liam Booth’s medical notes reported police were called after he became violent towards his father and resulted in officers taking the 12-year-old to the ED in handcuffs.
After counselling by the children’s mental health team finished in February 2009, Liam was not seen again by mental health services until early 2016, following a referral for help with drug use and low mood.
The next year and a half would see Liam Booth repeatedly engage with the Crisis Resolution team, alcohol and drug counsellors, community mental health and other agencies, with unremitting support from his parents, friends and flatmates, according to evidence to the coroner’s court.
His threats of self harm escalated during 2017, culminating in police bringing him to the ED in mid-September after he told his father of his plan to end his life.
On-call psychiatrist Dr Michael Clarke conferred with consultant psychiatrist Dr Katherine Hayes and decided Liam Booth did not meet the criteria to be compulsorily held under the Mental Health Act.
Liam Booth did not want to be admitted as a voluntary patient, and refused crisis respite.
Clarke discharged him, and he was given a taxi chit to get back to his flat.
That night formed the bulk of Geoff Booth’s complaint against the DHB.
He felt the hospital should have allowed him to be present at his son’s assessment, and did not believe the hour or so Clarke spent with Liam was long enough to assess him on their first meeting.
When Clarke phoned Geoff Booth after his son’s assessment, Geoff Booth warned him his son was lying when he said he did not have suicidal intentions, and urged him to admit him against his wishes.
By the time Clarke phoned Geoff Booth back later that night, his son had already been discharged.
Within weeks, Liam Booth would take his own life.
Court appointed expert witness, psychiatrist Dr Barry Walsh, found the quality of care Liam Booth received was adequate.
He told the Coroner compulsory treatment was a serious step, one that was often a “highly traumatising, frightening experience.”
“Further, with suicidal crises, admissions can cause a deterioration rather than an improvement,” he said.
Coroner Hesketh found the decision not to admit Liam Booth under the Mental Health Act was the right one, and cited research that found the focus on suicide risk factors was problematic, with tools or scales to assess risk used by an array of clinicians carrying “the kudos of science” despite “little evidence they are effective.”
Coroner Hesketh echoed the review findings that more should have been done to share information and include Liam Booth’s family in discharge planning.
He added a recommendation that Health NZ clarify with patients as soon as possible whether they consent to care and treatment plans being shared with family members.
If so, it was “imperative” families were kept updated and given the opportunity to have input, the Coroner said.
Health NZ told the Coroner all recommendations had been implemented, and it had added a Director of Lived Experience role to its mental health services leadership team who worked with consumer and family advisors to “translate principles into practice.”
The Coroner said he found Geoff Booth to be a “sincere witness” who at times “lacked objectivity.”
He had taken the evidence of Liam Booth’s doctors over his father’s, which meant he was entitled to review the draft findings, Coroner Hesketh said.
Geoff Booth raised several points in response, including asking what had happened to a pilot project for mental health co-response teams, made up of police, mental health and ambulance staff, which he felt would have helped his son.
Coroner Hesketh said the 2020 pilot was in response to the rapid escalation of mental health related 111 calls over the past decade, which now numbered about 73,000 a year.
The pilot included co-locating and jointly deploying staff from the three agencies who could provide advice to other responders as well as front-line capability for assessments and care in the community, avoiding the traditional response of police taking a distressed person to wait in an emergency department or a police station.
Mental health minister Matt Doocey last month announced the pilot was being expanded, with teams rolling out in Canterbury, Auckland, Bay of Plenty and Counties Manukau from June.
Geoff Booth also asked when a single record would be available covering GPs and public and private hospitals, noting Christchurch Hospital was unaware his son had visited his GP with suicidal ideation on the same day he was admitted to hospital.
The DHB informed the coroner a system called HealthOne operated throughout the South Island allowing access to certain records, but that it was “limited in terms of information flow”.
Coroner Hesketh said he was satisfied that even if a comprehensive system was available, it would not have made any difference to the decision to discharge Liam Booth.
On whether the death could have been prevented, the coroner said in his report the answer, sadly, was ‘no’.
HealthNZ has been approached for comment.
Geoff Booth could not be reached for comment.
Where to get help:
- Need to Talk? Free call or text 1737 any time to speak to a trained counsellor, for any reason
- Lifeline: 0800 543 354 or text HELP to 4357
- Suicide Crisis Helpline: 0508 828 865 / 0508 TAUTOKO. This is a service for people who may be thinking about suicide, or those who are concerned about family or friends
- Depression Helpline: 0800 111 757 or text 4202
- Samaritans: 0800 726 666
- Youthline: 0800 376 633 or text 234 or email talk@youthline.co.nz
- What’s Up: 0800 WHATSUP / 0800 9428 787. This is free counselling for 5 to 19-year-olds
- Asian Family Services: 0800 862 342 or text 832. Languages spoken: Mandarin, Cantonese, Korean, Vietnamese, Thai, Japanese, Hindi, and English.
- Rural Support Trust Helpline: 0800 787 254
- Healthline: 0800 611 116
- Rainbow Youth: (09) 376 4155
- OUTLine: 0800 688 5463
- Aoake te Rā bereaved by suicide service: or call 0800 000 053
If it is an emergency and you feel like you or someone else is at risk, call 111.
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– Published by EveningReport.nz and AsiaPacificReport.nz, see: MIL OSI in partnership with Radio New Zealand